The Norwegian naloxone program:
Experiences from implementing and results
Desiree Madah-Amiri, PhD
Norwegian Centre for Addiction Research ThINC 2, 2017
Oslo, Norway
Overview
• Project structure
• Findings
• Barriers and facilitators for distribution
Take-home naloxone in Norway
• National overdose prevention strategy
• Includes distribution of naloxone in 2 pilot cities
• Funding provided
• Novel intranasal device
• Prescription-free
• Access to existing network
Train-the-trainer model
• How to prepare staff for the new role?
• Train-the-trainer model
– >500 staff trained in first 18 months
– Currently over 1000
Madah-Amiri, Clausen, & Lobmaier. Drug alcohol depend. 2016
Findings
Yearly and total distribution July 2014-December 2016
0 500 1000 1500 2000 2500 3000 3500 4000 4500
2014 2015 2016 Total
Initial and refill distribution July 2014-December 2016
0 200 400 600 800 1000 1200
2014 2015 2016
Initial Refill
0 200 400 600 800 1000 1200 1400 1600 1800 2000
Oslo Bergen
Initial Refill Total
Per population
Initial and refill distribution by city
How to best report numbers?
• Through orders?
• Through reports from distribution sites?
• Through questionnaire data?
• Each paint a very different picture
Distribution 2015-2016
0 500 1000 1500 2000 2500 3000 3500 4000 4500 5000
Ordered Reported Forms Consent forms
43% of what we know was reported
Distribution facility type 2014-2016
0 5 10 15 20 25 30
Safe injection
facility
Low threshold
facility
Medical Mobile clinic Street outreach
Prison Shelter
2 low threshold
facilities responsible for nearly 50% of total distribution
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
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
Madah-Amiri, Clausen, & Lobmaier, Drug Alcohol Depend, 2016
Refills
• 73% participated in the refill survey
• From 2014-2016
– 554 successful reversals
– 70% of returns were initially used for OD
• Successful in 95% of cases
42% used 1 or 2 doses 27% used entire 5
dose spray
Madah-Amiri, Clausen, & Lobmaier, Drug Alcohol Depend, 2016
Findings
• Indication that target group met
– Increasing distribution rates, refills, and reported saves to an at-risk group
• 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
Staff and site participation
• Over 1000 staff trained from 70 different facilities
– Some sites/staff participated more than others
• Medical facilities vs. low threshold facilities
– What factors contributed to project
engagement/ barriers to participation?
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
• Reliable reporting and questionnaire data
Facilitators
• Staff buy-in was key in their participation
• Leadership involvement at each site
• Low-threshold facilities
– Ideologically aligned
• Collaboration and coordination
• Funding, prescription-free device
Conclusion
• Multi-level engagement helped to initiate the project and achieve high distribution rates
– BUT sustained collaborative involvement is necessary for sustainability and scaling up
• Continued emphasis on effective monitoring and reporting
– Evaluate coverage
Acknowledgements
Naloxone ninjas
Åse Merete Solheim (Bergen) Øystein Bruun Ericson (Oslo) Vibeke Kleveland (Trondheim)
SERAF
Philipp Lobmaier (MD, PhD) Thomas Clausen (professor, PI)
Pharmaceutical industry (DnE) Jenny Teigene and colleagues
Directorate of Health Martin Blindheim
Ambulance services
Guttorm Brattebø (Bergen), Arne Skulberg (Oslo)
