Take-home naloxone in multicentre emergency settings: the TIME feasibility cluster RCT
Authors: Snooks Helen , Benger Jonathan , Bell Fiona , Black Sarah , Dixon Simon , Emery Helena , Evans Bridie Angela , Fuller Gordon , Hoskins Rebecca , Hughes Jane , Jones Jenna , Jones Matthew , Johnston Sasha , Long Jaqui , Moore Chris , Parab Rakshita , Pilbery Richard , Sampson Fiona C , Watkins Alan 
Published: November 2024

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.

Results

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’ (n = 136); ‘too busy’ (n = 15); suspected intentional overdose (n = 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 Health Technology Assessment; Vol. 28, No. 74. See the NIHR Funding and Awards website for further award information.