Impact case study database

Against a backdrop of escalating opioid use and overdose deaths, King’s research has built on our 2014 case study to improve THN implementation and availability by developing a more user-friendly and acceptable nasal spray. Our research into the role of training in the effectiveness of THN has underpinned changes in policies and practices in the UK, the US and globally, and increased the availability of naloxone, saving lives worldwide in 23 countries which now have documented THN programmes [A].

King’s research drove and informed commercial development of naloxone in the form of a nasal spray. Based on the strength of King’s research ( 5), Mundipharma decided to test and develop nasal spray forms of naloxone. King’s researchers contributed to the design of trials and collaborative research ( 7) that formed the evidence base for the regulatory approval of the resulting product, Nyxoid, across Europe and Australia. Nyxoid is progressively being introduced into public policy and clinical practice [B1, B2, B3].

King’s research led to UK policies recommending THN, and its implementation.

UK Government approval for THN was confirmed in 2015, with nasal naloxone added in 2019 [C1], referencing for advice an open letter describing King’s THN research on the necessity for training [C2]. The development of Public Health England (PHE) clinical national guidelines (AKA the Orange Guidelines), featuring King’s research on THN ( 5) and chaired by King’s researcher Strang, influenced Government decision making [C3]. In England 95% of local authorities now provide THN and 40,033 THN kits were dispensed in community settings in 2017/18 [C4]. In Northern Ireland the Public Health Agency’s THN programme supplied 1,332 kits in 2018/19 [C5]. In Scotland, 8,379 THN kits were distributed in the year 2017/18 [C6]. In Wales 4,120 THN kits were issued in 2017/2018 [C7]. Based on King’s research, pilot schemes were launched in 2020 to train police officers to administer naloxone in North Wales, Durham and West Midlands. The North Wales Police and Crime Commissioner said: “The research carried out by King’s College London on the effectiveness of naloxone in saving lives of those experiencing an overdose contributed to the vision of piloting officers carrying naloxone in North Wales.” Police officers on the pilot have already saved lives [C8]. The chair of the expert sub-committee of the Advisory Council on the Misuse of Drugs which is examining THN, and makes recommendations to the UK government, cites King’s research ( 3,4) as shaping its understanding of the potential for further public benefit from the expansion of THN in the UK [C5].

King’s research informed US policy on THN for overdoses of prescription opioids.

In 2017 alone, an estimated 47,600 people died from opioid overdose in the US. King’s researchers have been influential in the development of US policy to address this widespread problem. Professor Keith Humphreys, previously Senior Policy Advisor for the Obama administration, included naloxone in the 2010 US Drug Strategy [D1], which paved the way for a host of subsequent policies widening the availability of THN. For example, in 2016 the US Surgeon General endorsed THN [D2, D1], and in 2018, Congress passed the SUPPORT Act (Substance Use-Disorder Prevention that Promotes Opioid Recovery and Treatment for Patients and Communities Act) [D3, D1]. In 2016 Humphreys ‘used Professor Strang’s work extensively in working with Congress on the CARA Act (Comprehensive Addiction and Recovery Act 2016), which expanded naloxone even further, allocating over $180 million to provide naloxone to individuals taking prescribed or illicit opioids and their families’ [D1, D4]. Nasal and injectable THN kits are now provided to PWUOs in the US, and co-prescribed with opioids for medical treatment. King’s research has resulted in naloxone being used by police officers, homeless shelter workers, firefighters, prison staff, as well as opioid users and their families. Naloxone prescriptions more than doubled from 270,000 to 576,000 from 2017 to 2018 [D5], and in 2019, 94% of Syringe Service Programs in the US implemented overdose education and naloxone distribution compared to 55% in 2013 [D6].

King’s research influenced global THN policies. King’s researchers advocated for and contributed to the first-ever guidelines from the WHO on the ‘Community Management of Opioid Overdose’ (2014) [E1, E2]. The guidelines draw heavily on King’s research ( 2,3) to call for increased availability of THN and training. In 2016 King’s research underpinned a declaration from the United Nations General Assembly calling for national policies to include THN [E3, E2], leading to widespread uptake [A]. King’s research directly contributed to the UNODC Stop Overdose Safely 90-90-90 S-O-S initiative [E4,E2]. King’s researchers also co-designed and co-delivered UNODC strategy for the implementation and evaluation of THN provision at national and regional levels in countries that either produce heroin or are located along the trade routes for heroin to Western Europe. Anja Busse, UNODC, says King’s researchers: “have been invaluable contributors to UNODC's development of training materials, international training events in countries including Kyrgyzstan, Kazakhstan, Tajikistan, and regional training events in Iran which was also for Afghanistan and neighbouring countries… [these] underpin the development of Take-Home Naloxone provision in these countries which did not formerly have expertise in the public benefit of Take Home Naloxone” [E2]. As of August 2020, this initiative has delivered training to 16,000 potential witnesses of opioid overdose in Kazahkstan, Kyrgystan, Tajikstan and Ukraine and provided THN kits to 40,000 people as part of a study [E5].

The European Monitoring Centre for Drugs and Drug Addiction provides the European Union with evidence on European drug problems. King’s researchers authored its 2016 guide on best practices on THN [E6], where King’s research is featured ( 2,3,5), and the King’s Bradford Hill review ( 1) informs the Centre’s guidance on naloxone [E7]. King’s research has impacted policy decisions nationally in Europe. For example, King’s research supported the National Centre for Addiction Research in Norway in advocating for THN provision, leading to the launch in 2014 of a National Overdose Prevention Strategy distributing about 8,000 THN kits in the first four years. A 95% survival rate was recorded in about 600 uses of THN on overdose victims in the first 2.5 years [E8].

Take-Home Naloxone saves lives. King’s research continues to demonstrate the effectiveness and feasibility of THN as a public health intervention, whilst advocating for increased provision and training to ensure that THN is available in the community to save lives. In Northern Ireland alone THN was administered 240 times in 2018-19 and was successful in reversing an opioid overdose in over 90% of cases. As Michael Owen, Lead for Drugs and Alcohol at Northern Ireland’s Public Health Agency said: “each overdose reversal is an occasion when a person could have died, but didn’t” [F1]. First-hand accounts from those who have been trained to use THN demonstrate its powerful impact. A PWUO who had saved the life of his friend with THN said “I’ve administered naloxone once to a friend of mine who was minutes away from death…gasping for air and barely breathing…and within a minute she was sitting up and talking. It was that simple and that quick” [F2]. The development of the more acceptable nasal spray coupled with THN training have together empowered a broader range of witnesses to receive training and administer THN. The British Red Cross deliver such training to PWUO, their friends and families. One of their delegates said “just knowing and saving someone’s life, it’s better than any drug in the world you know, any drug in the world” [F3]. These changes in THN availability and use could not have happened without King’s research identifying the barriers to use, improving the product, providing the evidence to increase uptake, and influencing policy across the world.