Research paper
Impact of training for healthcare professionals on how to manage an opioid overdose with naloxone: Effective, but dissemination is challenging

https://doi.org/10.1016/j.drugpo.2010.09.008Get rights and content

Abstract

Background

Opioid overdose has a high mortality, but is often reversible with appropriate overdose management and naloxone (opioid antagonist). Training in these skills has been successfully trialled internationally with opioid users themselves. Healthcare professionals working in substance misuse are in a prime position to deliver overdose prevention training to drug users and may themselves witness opioid overdoses. The best method of training dissemination has not been identified. The study assessed post-training change in clinician knowledge for managing an opioid overdose and administering naloxone, evaluated the ‘cascade method’ for disseminating training, and identified barriers to implementation.

Methods

A repeated-measures design evaluated knowledge pre-and-post training. A sub-set of clinicians were interviewed to identify barriers to implementation. Clinicians from addiction services across England received training. Participants self-completed a structured questionnaire recording overdose knowledge, confidence and barriers to implementation.

Results

One hundred clinicians were trained initially, who trained a further 119 clinicians (n = 219) and thereafter trained 239 drug users. The mean composite score for opioid overdose risk signs and actions to be taken was 18.3/26 (±3.8) which increased to 21.2/26 (±4.1) after training, demonstrating a significant improvement in knowledge (Z = 9.2, p < 0.001). The proportion of clinicians willing to use naloxone in an opioid overdose rose from 77% to 99% after training. Barriers to implementing training were clinician time and confidence, service resources, client willingness and naloxone formulation.

Conclusions

Training clinicians how to manage an opioid overdose and administer naloxone was effective. However the ‘cascade method’ was only modestly successful for disseminating training to a large clinician workforce, with a range of clinician and service perceived obstacles. Drug policy changes and improvements to educational programmes for drug services would be important to ensure successful implementation of overdose training internationally.

Introduction

Opioid overdose has a high mortality, but opioid overdose can be reversed with appropriate overdose management and naloxone (opioid antagonist/heroin antidote) training. Internationally, reducing drug related deaths and harms associated with drug use is a priority. The United Kingdom (UK) government aims to reduce the number of drug related deaths, in particular overdoses related to heroin, which contribute to a substantial proportion of deaths. Concern was increased when a sharp rise in the prevalence of opioid overdoses was recorded (Morgan et al., 2006). A number of measures have been proposed to reduce overdose deaths in the UK (Advisory Council on the Misuse of Drugs, 2000), including the wider provision of opioid substitution treatment (Office for National Statistics, 2006). However, these measures have not achieved the government target of a 20% reduction in drug mortality and an increase in deaths was recorded in 2005 (Department of Health, 2008).

Up to 56% of opioid users in contact with treatment services have reported an opioid overdose during their lifetime with 77% having witnessed an opioid overdose (Best et al., 2002). Opioid overdose training and take home naloxone have been proposed as one possible method for reducing drug related deaths caused by opioid overdose (Strang, Kelleher, Best, Mayet, & Manning, 2006). This training aims to help healthcare professionals become confident at managing an opioid overdose when this occurs at the drug treatment centre (Dettmer, Saunders, & Strang, 2001). Additionally and probably more usefully, clinicians can extend training to their patients, carers and family members and provide them with take home naloxone as they may be more likely to witness an opioid overdose and respond (Baca and Grant, 2005, Sporer and Kral, 2007, Strang et al., 2006, Strang, 1999).

The opioid antagonist ‘naloxone hydrochloride’ can be prescribed for take home use which may reduce drug related deaths, as this intervention can be used to reverse the effects of an opioid overdose. Naloxone hydrochloride is a short-acting opioid antagonist, which has been used for more than 40 years for the reversal of opioid overdoses (Clarke et al., 2005, Osterwalder, 1996). However due to the rapid effects of an opioid overdose causing death by respiratory depression; naloxone needs to be given quickly after an opioid overdose, to be effective. Providing take home naloxone to drug users and their carers means that potentially naloxone is available quickly following an opioid overdose.

In 2005, naloxone was reclassified in the UK, and was added to a list of prescription-only medications that can be administered by anyone in an emergency for the purpose of saving a life (The Medicines for Human Use (Prescribing), 2005). Reports of prevented deaths with take-home naloxone have been published since 2001 (Dettmer et al., 2001). Most studies have shown improvement in knowledge and attitudes after overdose training amongst drug users (Dietze et al., 2006, McAuley et al., 2009, Office for National Statistics, 2006, Strang et al., 2008, Tobin et al., 2009Wagner et al., 2009, Worthington et al., 2006) but very little is known about those clinicians who provide training to drug users. Disseminating and evaluating training for clinicians working in the addictions field, where clinicians have different professional backgrounds and competencies, with very close contact to drug users, is important for ensuring consistency of care and to assess whether this training is effective.

Training drug users how to manage an opioid overdose and use naloxone can help drug users effectively distinguish opioid overdose symptoms and undertake appropriate management including the administration of naloxone (Green, Heimer, & Grau, 2008). For professionals to help with disseminating training to drugs users and family members, it is essential that they have the necessary knowledge and skills to manage an opioid overdose, to transfer the knowledge effectively. It has been identified that more knowledgeable clinicians are more likely to support naloxone provision for drug users (Beletsky et al., 2007, Coffin et al., 2003, Tobin et al., 2005b). Secondly whilst some studies have published the curriculum and method used to train their clinicians (Doe-Simkins et al., 2009, Maxwell et al., 2006), methods for providing training in these groups has not been evaluated. With growing numbers of clinicians working in the drugs field internationally; a mechanism for providing relatively inexpensive training to clinicians (who can then deliver the training to drug users) is desirable.

One possibility for disseminating training cost-efficiently, is the use of the ‘cascade method’, whereby trained clinicians become ‘trainers’ and train other clinicians and drug users (Coulthard and Craig, 2006, Giusti et al., 2006, Loveday, 2001). This training method has been advocated as efficiently providing quality training to medical staff in the UK (Draper, Silverman, Hibble, Berrington, & Kurtz, 2002). Additionally the cascade method has been highly successful with training healthcare workers of people with HIV/AIDS internationally (Giusti et al., 2006, O’Keeffe and Sims, 1998). The cascade method has not been evaluated with opioid overdose training in the drugs field and may provide a potentially efficient training method when resources are limited. If this type of training dissemination is effective in the drugs field, this could be a good mechanism for providing inexpensive training to clinicians and drug users, especially important where resources are scarce.

The aim of this study was to (i) evaluate clinician's knowledge and confidence on opioid overdose management and administering naloxone pre and post training; (ii) test the efficiency of the ‘cascade method’ for disseminating overdose training; and (iii) identify barriers to clinician and client training and identify why some services were more successful at implementing training than others.

Section snippets

Design

A repeated-measure design assessed changes in knowledge and confidence on opioid overdose management and administering naloxone before and immediately after training. To evaluate the ‘cascade method’, the sample was followed up for one year. A local lead collated data, recording the number of clinicians and drug users subsequently trained at each site, and returned the completed training questionnaires to the research coordinators at the National Addiction Centre (London). The first group of

Results

In total, 219 clinicians were trained. One hundred (45.7%) were initially trained over four large training sessions. The ‘trained’ clinicians trained a further 119 clinicians (54.3% of sample). The 219 trained healthcare professionals trained a total of 239 drug users over the following 12 months (third wave) whereby drug users were trained in opioid overdose management and prescribed naloxone to take home (Strang et al., 2008). Of the 219 trained clinicians, 198 (90.4%) completed a pre

Discussion

For the technology transfer to be successful, it is not only the technology that must work, but also the transfer. This study has focused on the practical aspect of implementing opioid overdose and naloxone training to clinicians in addictions services via a ‘cascade method’. Whilst training significantly improved individual knowledge and confidence of clinicians when dealing with an opioid overdose; the ‘cascade method’ was only modestly successful for disseminating training to a large

Limitations

Interpretation of these findings should take account of the study limitations. It is possible that social desirability and selection bias could have over represented high levels of knowledge and confidence, in that the most motivated and knowledgeable clinicians would have taken part in the study. Barriers were assessed in a sub-set of clinicians and not the complete sample.

Conclusion

This is the first paper to report on the extent to which clinicians benefit from opioid overdose management and naloxone administration training. We found that generally clinicians were able to recognise the risks, signs and appropriate actions following an opioid overdose. However this was not a universal finding with a significant minority demonstrating a lack of overdose knowledge before training. This must surely be incompatible with the intention of having an appropriately trained and

Acknowledgements

The opioid overdose training was funded by the UK National Treatment Agency for Substance Misuse (NTA).

We are grateful to all clinicians from the addiction services who accepted to take part on this study.

Conflict of interest: JS has received research grants, travel and conference expenses, honoraria and consultancy fees from several pharmaceutical companies including producers and suppliers of pharmaceutical opiates.

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