As Overdose Awareness Day approached, the millionth kit of injectable naloxone was distributed. DDN looks back at the story of this lifesaving intervention. Naloxone was first developed in the 1960s and used by the emergency services to reverse opioid overdose. It wasn’t until 2005 that it was made available under UK law to be administered by anyone for the purpose of saving a life – but it would be another ten years before drug services could supply naloxone without a prescription. Evidence swiftly mounted on the success of pilot programmes, showing overdoses were reversed each time it was used. By 2008 we were hearing from groups of clinicians and user groups who were championing the cause with tangible results – but without national guidance or support. The Scottish Government, in recognition of ever-escalating drug-related death statistics, recommended the provision of take-home naloxone (THN). But there were still concerns about legislation and the practicalities of obtaining a ‘prescription-only medicine’ and anxiety around using it. At this point naloxone didn’t feature in National Treatment Agency (NTA) targets, but the following year the NTA announced that families and carers of injecting drug users would be trained to administer naloxone in 16 sites across England. There were calls for the pilot to be extended to drug users and their peers – those most likely to be present at the time of an overdose. By 2012 a ruling in Scotland allowed homeless hostel staff to hold naloxone ready for emergency use without prescription; there was optimism that a wider rollout could be getting closer for the whole of the UK. The first licensed THN product, launched in 2013, pushed open the gate to widening access. Its distribution was still a postcode lottery and there would still be many hurdles to overcome, but pressure was building on commissioners, clinicians, treatment services and prisons to take naloxone seriously and to incorporate it as essential harm reduction. You Need To Get Angry By 2014 Scotland, Wales and Ireland each had national programmes of naloxone distribution in place, but in England it had been left up to localism. Activism was audible – ‘you need to get angry. You should all be persuading your commissioners that we need naloxone.’ Some prisons took the initiative on naloxone, but many didn’t. Those which introduced a THN programme to equip prisoners on release took a massive step towards protecting those vulnerable to overdose. GPs joined the call for everyone to spread the word on naloxone. ‘We need those of you who work with clinicians, those who commission services and those who provide education to recommend the prescribing of naloxone,’ said our regular GP columnist Dr Steve Brinksman, while Dr Judith Yates told us: ‘I believe that it may come to be seen as negligent to prescribe methadone without also prescribing a take-home naloxone kit.’ The Naloxone Action Group (NAG), a group of service users, treatment workers and medical professionals, examined the ‘postcode lottery’ through a survey and vowed to challenge every area of the country that was slow or reluctant to roll out distribution or training. Release were ready to challenge non-provision through legal action, with ‘very strong right-to-life and human rights arguments,’ said Niamh Eastwood. Outreach worker and activist Philippe Bonnet, who delivered naloxone training at the 2015 DDN Conference, urged: ‘Identify champions and knock down doors, and make use of the service user groups and advocacy groups that can do that on your behalf. But don’t take no for an answer.’ But there was still no national programme or requirement to provide naloxone in England, and the postcode lottery continued. Chris Rintoul, then lead trainer for Street Rx in Northern Ireland, was in no doubt that the Scottish Drugs Forum (SDF) had ‘watered the seeds of take-home naloxone’ and allowed them to kick-start the programme in NI. ‘Before that we had no naloxone, and no sight of it,’ he said. ‘Some of the action involved aggressive campaigning’, developing partnerships with all stakeholders. Drop in Overdoses When a change in the law in England allowed outreach services and hostels to give out naloxone, as well as pharmacies, a significant drop in overdoses seemed like no coincidence. Meanwhile on the international stage, the EMCDDA published a Europe-wide review of the case for distributing naloxone, which included good practice and training examples, as well as looking at the legal barriers to distribution. As the record number of drug-related deaths dominated DDN conference debate in 2017, Alex Boyt drew attention to the fact that ‘people who are dying are not in service, while the naloxone doses are being given to those who are in service. But we’re in a situation where the budgets are being cut so severely that people are just clinging on to what they do and not trying anything new. We need to be saturating the drug-using community with naloxone.’ A few months later Alex Stevens, professor of criminology at the University of Kent said he was ‘saddened and angry’ that commissioners hadn’t got the message that naloxone should be provided to anyone who comes into contact with a person who could be at risk of overdose. The Local Government Association (LGA)’s Naloxone survey 2017 showed that 90 per cent of English local authorities were making THN available, through treatment services, hostels and outreach workers. But Release examined the THN statistics through freedom of information requests and found that just 12 take-home kits were being given out for every 100 people using opiates. Levels of naloxone provision by local authorities were ‘chronically inadequate’ they stated, as statistics showed opiate-related overdose deaths to be the highest since records began. Concern was not limited to the sector. Calls for change were being heard from senior police and crime commissioners, who said a ‘grown-up conversation about drugs’ needed to involve equipping the police with naloxone. And while we found some examples of highly effective prison healthcare, treatment providers were finding it rare for any of their service users to have been provided with naloxone on release from prison. The government confirmed in 2018 that there were no plans to make this a mandatory requirement for prisons. Upward Trends Activism scaled up further in response to diminishing treatment budgets. ‘Imagine what the drug-related death figure would be if naloxone wasn’t about,’ said Mick Webb, while George Charlton – whose alter ego Naloxone Man would become a regular sight – said: ‘If we’re not giving out naloxone, we’re giving the message that it doesn’t matter if you die. Overdose is reversable, death is not.’ In examining the ‘substantial upward trend’ in drug-related deaths, the Drug, Alcohol and Justice Cross-Party Parliamentary Group concluded that naloxone was ‘simply not reaching the people who need it the most’. The COVID-19 pandemic brought new fears – lockdown measures were compromising the purity of many drugs and dwindling budgets were having an impact on naloxone provision. As 2021 dawned, the government announced an £80m investment in drug treatment in England. Targeted at reducing crime, its ‘system-wide approach’ would include funding naloxone provision for ‘every heroin user in the country that needs it’. Partnerships with police teams and custody suites were encouraging police officers to carry kits. Scotland swiftly followed with a pledge of £250m to tackle its record high rates of drug-related deaths and would use some of the money to widen naloxone distribution. A Stop the Deaths campaign included a dedicated website where people could order kits, and Police Scotland confirmed that officers right across Scotland would be equipped with naloxone. Further Provision Alongside the government’s announcement that 50 of England’s most deprived areas would receive significantly more funding came the opportunity to further widen naloxone provision in 2022, and the ACMD identified a key role for community pharmacies. Scotland’s Drugs Death Taskforce said developing the world’s most extensive naloxone network was still a key aim in a very necessary public health approach. As we entered 2023 the SDF shared evaluation of pilot peer-to-peer naloxone programmes in three settings – one urban, one rural and one in prison – which showed the power of peer involvement in saving lives with naloxone. Reporting on initiatives from across the UK in DDN has confirmed the essential role of peers, right up to inspirational presentations at the DDN conference. As we commemorate another Overdose Awareness Day there is much to acknowledge – the millionth injectable naloxone kit being distributed to save yet another life – yet still much to do. There are still too many people who have never heard of naloxone, let alone been trained in what to do with it. Do you carry a kit? DDN This article has been produced with support from an educational grant provided by Ethypharm, which has not influenced the content in any way. Related articles (Features September 2023): Naloxone is safe and easy to use. So let’s get lots more people trained up and carrying it, says Deb Hussey. (Features February 2023): Turning Point hosted its first Safer Lives conference in Birmingham making a commitment to addressing the drug death crisis. (News August 2023): An app to highlight places such as pharmacies and needle exchanges that offer free naloxone has been launched by Turning Point and Somerset Council. (The DDN Conference 2023): Cranstoun’s Worcestershire service talk about their peer-led naloxone team, PACKS – ‘peer-assisted community knowledge and support’. (News March 2023): Peer-to-peer naloxone programmes can help to reduce stigma and boost confidence, says a new report from the Scottish Drugs Forum Search for naloxone distribution and harm reduction vacancies on DDN jobs Read more on harm reduction and naloxone distribution in our archive.