1. Experiences from a national overdose prevention strategy: Nasal naloxone distribution and lessons learned
Philipp Lobmaier, MD, PhD Norwegian Centre for Addiction Research (SERAF)
Oslo University Hospital

2. Background National Overdose Prevention Strategy
“Switch your habits” campaign to inhale
Working alliance of 14 regions with highest OD mortality
Bystander administered nasal naloxone

3. Preparations Acquisition of intranasal device
Ability to distribute without prescription
Approval for any staff to distribute

4. Aims
To establish access to nasal naloxone for bystanders starting in 2 pilot cities
To achieve sufficient coverage: 100 sprays per pop per year
To evaluate the programme by self-report and record linkage

5. Materials & method Target groups
People who inject drugs (PWID) and their friends and families
Staff working with PWID
Staff from existing facilities trained to be naloxone trainers (2-hour course)
Utilized existing low-threshold networks as distribution points

6. Overdose prevention training
Clients learn about overdose risk factors, recognition and response
Ambulance
Rescue breathing
Naloxone
Recovery position & aftercare

7. Findings

8. Participant characteristics
85% were opioid users
Most exhibited at least one known risk factor for overdosing
Periods of non-use
Using while alone
Mixing opioids with other drugs
Injecting
(Madah-Amiri, Clausen & Lobmaier, Drug Alcohol Depend 2016 )

9. Initial training
Nearly all (92%) had witnessed or experienced an overdose
60% have witnessed more than 10 overdoses
30% of those that had experienced an overdose had had more than 10

10. Yearly and total distribution July 2014 - December 2016
2014= 729
2015=1327
2016=1770
Combined total: 3826

11. Initial and refill distribution July 2014 - December 2016
Since the beginning of the project in 2014 we have observed an increasing trend in naloxone distribution.
This graph includes numbers for all sites in all cities from the start of the project until the end of 2016.
It total, 3865 naloxone were distributed by the end of 2016, with 1536 (40%) being for refills. We observed increasing returns for refills, which gives an indication of reaching the target population.

12. Distribution by Facility type (2014-2016)
2 low threshold facilities responsible for nearly 50% of total distribution
Various types of distribution facilities are involved in the project. By the end of 2016, there were 58 distribution facilities participating, and as of today, there are approximately 70.
While medical facilities made up the majority of sites, low threshold facilities distributed the most naloxone.
To illustrate this, 2 low threshold facilities were responsible for 47% (n=1823) of the total distribution.

13. Refills 73 % participated in the refill survey Between 2014 and 2016
554 successful reversals
70% of returns were initially used for OD
Successful in 95 % of cases
(Madah-Amiri, Clausen & Lobmaier, Drug Alc Depend 2017;173:17-23)
73% of those that returned for a refill consented to participate in the study
Of the people that returned, and consented, 70% (n=586) were used on an overdose
Reported successful reversals for 95% (n=554). The remaining were unknown outcomes (n=10), missing outcomes/form left blank (n=18), 1 conflicting form, and 3 deaths.

14. Findings summary Indication that target group met
High distribution rates, refills, and reported saves
Naloxone was successful at nearly all events
Coordinated use of existing network offered access to heterogeneous group
Low-threshold facilities had the highest rates of distribution

15. Staff and site participation
Over 1000 staff trained from 70 different facilities
Some sites/staff participated more than others
Factors contributing to project engagement
Facility type: harm reduction policy adopted, street level servicing
Staff and leadership synergies embracing the naloxone intervention: making time and space

16. Barriers
«Top down» approach subject to resistance and lack of interest
Externally motivated initiatives may be vulnerable to sustained participation
New trainer role
Resistance to increased workload
Skeptical towards «new» intervention

17. Facilitators Staff buy-in was key in their participation
Leadership involvement at each site
Collaboration and coordination
Funding as part of strategy
Prescription-free device

18. Conclusion
Multi-level engagement helped to initiate the project and achieve high distribution rates
Sustained collaborative involvement necessary for sustainability and scaling up

19. Acknowledgements
Naloxone ninjas Åse Merete Solheim (Bergen) Øystein Bruun Ericson (Oslo) Vibeke Kleveland (Trondheim) SERAF Desiree Madah-Amiri (PhD student) Thomas Clausen (professor, PI) Pharmaceutical industry (DnE) Jenny Teigene and colleagues Directorate of Health Martin Blindheim Ambulance services Guttorm Brattebø (Bergen), Arne Skulberg (Oslo)