Naloxone from Hospital to Home. Improving access to take-home naloxone (THN) on discharge from acute medical care in Scotland

需要解决的问题和开展这项拟议研究的理由2015年，世卫组织报告称，全球有45万人死于药物使用，其中167,750人直接与药物使用障碍有关(禁毒办，2018年)。苏格兰与毒品相关的死亡率继续同比上升，2017年有900多人死亡，是有记录以来最高的年度总数。在英国国家之间，苏格兰的DRD比率约为每百万人死亡175人，而英格兰和威尔士为66.1人(英国国家统计局，2017年)。在苏格兰2017年的934个DRD中，87%涉及阿片类药物，一直是DRD的最主要原因(NRS 2018)。阿片类药物相关死亡的高风险时间是戒除后的一段时间，包括监狱释放、戒毒后或住院康复和住院后出院，可能是由于阿片类药物耐受性降低(Strang等人，2014年)。纳洛酮是一种短效阿片受体拮抗剂，可逆转阿片类药物过量的潜在致命影响(White&Irvine，1999)。它没有明显的滥用潜力，并保持了良好的安全状况(Strang等人，2013年)。国家纳洛酮计划(NNP)旨在通过向处于危险中的人提供带回家的纳洛酮(THN)，为同行管理的目的，为减少苏格兰的ODS做出贡献。NNP包括过量风险意识、复苏应急管理和肌肉注射纳洛酮方面的培训。纳洛酮被提供给阿片使用者、家庭成员或服务工作者，用于目睹过量服药的情况，以便紧急服务及时到达并促使进一步治疗(McAuley等人，2012年)。研究表明，THN计划可以提高与过量服药相关的知识、管理技术，并与过量服药生存密切相关(McDonald&Strang 2016)。最近更新的苏格兰毒品和酒精战略(苏格兰政府2018年)认识到减少危害措施的重要性和影响，并特别强调要求向所有有ORD风险的人提供纳洛酮。迄今为止，国家警察通过在解放前提供纳洛酮的使用和培训，在处理监狱释放后的违禁药物方面取得了重大成功；2016年，3.5%的违禁药物在获释后四周内使用，2017年为4.4%，而在实施之前的五年中，这一比例为9.8%(国家警察监测报告2017/18)。不幸的是，苏格兰的出院后ORD水平有所上升；2017年，11%的ORD在出院后四周内观察到，而在NNP之前的五年中，这一比例为9.7%(NNP监测报告2017/18)。因此，虽然对监狱后违约金产生了重要影响，但对医院后违约率没有影响。对出院后增加的过量用药风险缺乏认识可能是一个促成因素(Bird等人，2017)。许多面临阿片类药物过量风险的人不经常参加专门的药物治疗服务，这是迄今为止获得纳洛酮的主要途径。此外，由于无法获得医疗保健和初级保健服务工作者的耻辱，许多使用阿片类药物的人推迟寻求帮助，直到健康问题变得严重，他们被迫使用紧急服务(Ayres等人，2012年)。因此，纳洛酮分配的一个自然接入点是急性医疗护理。这一关键问题的政策轮廓现在很高，但需要强有力的实用战略，以确保纳洛酮的充分利用。

Problem to be addressed and rationale for undertaking the proposed researchIn 2015, the WHO reported 450,000 global deaths due to drug use, with 167,750 directly associated with drug use disorders (UNODC, 2018). Scottish rates of drug-related death (DRDs) continue to rise year on year, with over 900 deaths in 2017, the highest ever recorded annual total. Between UK nations, Scotland's DRD rate sits at approximately 175 per million deaths, compared to 66.1 in England and Wales (ONS, 2017). Of the 934 DRDs in Scotland in 2017, opioids were implicated in 87% of these, consistently remaining the most prominent cause of DRDs (NRS 2018). High risk times for opioid related deaths (ORDs) are periods following abstinence including post prison release, post detoxification or residential rehabilitation, and post hospital discharge, likely due to lowered opioid tolerance (Strang et al 2014). Naloxone is a short-acting opioid receptor antagonist which reverses the potentially fatal effects of opioid overdose (White & Irvine, 1999). It has no obvious potential for abuse and maintains a good safety profile (Strang et al, 2013). The National Naloxone Programme (NNP) aims to contribute to a reduction in ORDs in Scotland through provision of take-home naloxone (THN) to those at risk for the purposes of peer administration. The NNP involves training in overdose risk awareness, emergency management with resuscitation and intramuscular naloxone administration. Naloxone is provided to opioid users, family members or service workers, for use in witnessed overdose situations to allow emergency services time arrive and instigate further treatment (McAuley et al, 2012). Research indicates THN programmes can improve overdose-related knowledge, administration techniques and have a strong association with overdose survival (McDonald & Strang 2016). The recently updated Scottish drug and alcohol strategy (Scottish Government 2018) recognises the importance and impact that harm reduction measures can have, and specifically highlights the requirement to provide naloxone to all those at risk of ORD. To date, the NNP has had significant success in tackling post prison release ORDs via provision of, and training in, use of naloxone prior to liberation; 3.5% of ORDs were four weeks post release in 2016 and 4.4% in 2017, compared to 9.8% in the five years prior to NNP implementation (NNP Monitoring Report 2017/18). Unfortunately, Scottish post hospital discharge ORD levels have increased; 11% of ORDs observed within four weeks post hospital discharge in 2017, compared to 9.7% in the five years preceding the NNP (NNP Monitoring Report 2017/18). Thus, whilst there has been an important effect on post prison ORDs, there has been no impact on post hospital rates. Lack of recognition of heightened overdose risk after discharge is likely to be a contributing factor (Bird et al, 2017). Many at risk of opioid overdose do not routinely engage with specialist drug treatment services which has been the main route to accessing naloxone thus far. In addition, due to inaccessible healthcare and perceived stigma from those working in primary care services, many people who use opioids delay seeking help until a health problem becomes severe and they are forced to use emergency services (Ayres et al, 2012). A natural access point for naloxone distribution is therefore acute medical care. The policy profile of this critical issue is now high yet there is a need for robust practical strategies to ensure utilisation of naloxone to its full potential.