Take-home naloxone in multicentre emergency settings: the TIME feasibility cluster RCT.

BACKGROUND

Opioids kill more people than any other drug. Naloxone is an opioid antagonist which can be distributed in take-home 'kits' for peer administration (take-home naloxone).

AIM

To determine the feasibility of carrying out a definitive randomised controlled trial of take-home naloxone in emergency settings.

DESIGN

We used Welsh routine data (2015-21) to test the feasibility of developing a discriminant function to identify people at high risk of fatal opioid overdose. We carried out a cluster randomised controlled trial and qualitative study to examine experiences of service users and providers. We assessed feasibility of intervention and trial methods against predetermined progression criteria related to: site sign-up, staff trained, identification of eligible patients, proportion given kits, identification of people who died of opioid poisoning, data linkage and retrieval of outcomes.

SETTING

This study was carried out in the emergency environment; sites comprised an emergency department and associated ambulance service catchment area.

PARTICIPANTS

At intervention sites, we invited emergency department clinicians and paramedics to participate. We recruited adult patients who arrived at the emergency department or were attended to by ambulance paramedics for a problem related to opioid use with capacity to consent to receiving the take-home naloxone and related training.

INTERVENTIONS

Usual care comprised basic life support plus naloxone by paramedics or emergency department staff. The take-home naloxone intervention was offered in addition to usual care, with guidance for recipients on basic life support, the importance of calling the emergency services, duration of effect, safety and legality of naloxone administration.

DISCRIMINANT FUNCTION

With low numbers of opioid-related deaths (1105/3,227,396) and a high proportion having no contact with health services in the year before death, the predictive link between death and opioid-related healthcare events was weak. Logistic regression models indicated we would need to monitor one-third of the population to capture 75% of the decedents from opioid overdose in 1-year follow-up.

RANDOMISED CONTROLLED TRIAL

Four sites participated in the trial and 299 of 687 (44%) eligible clinical staff were trained. Sixty take-home naloxone kits were supplied to patients during 1-year recruitment. Eligible patients were not offered take-home naloxone kits 164 times: 'forgot' ( = 136); 'too busy' ( = 15); suspected intentional overdose ( = 3).

QUALITATIVE INTERVIEWS

Service users had high levels of knowledge about take-home naloxone. They were supportive of the intervention but noted concerns about opioid withdrawal and resistance to attending hospital for an overdose. Service providers were positive about the intervention but reported barriers including difficulty with consenting and training high-risk opioid users.

HEALTH ECONOMICS

We were able to calculate costs to train staff at three sites (£40 per AS and £17 in Site 1 ED). No adverse events were reported. Progression criteria were not met - fewer than 50% of eligible staff were trained, fewer than 50% of eligible patients received the intervention and outcomes were not retrieved within reasonable timescales.

FUTURE WORK

The take-home naloxone intervention needs to be developed and evaluated in emergency care settings, with appropriate methods.

LIMITATIONS

The Take-home naloxone Intervention Multicentre Emergency setting study was interrupted by coronavirus disease.

CONCLUSIONS

This study did not meet progression criteria for intervention or trial methods feasibility, so outcomes were not followed up and a fully powered trial is not planned.

TRIAL REGISTRATION

This trial is registered as ISRCTN13232859.

FUNDING

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/91/04) and is published in full in ; Vol. 28, No. 74. See the NIHR Funding and Awards website for further award information.