Service Evaluation of Scotland's Take-Home Naloxone Programme

4 The effectiveness of processes and structures

4.1 In this chapter, we examine the effectiveness of the identified processes and structures in place to implement the programme from the different perspectives of service providers, programme beneficiaries and their family members/carers/friends.

4.2 The evidence for this chapter is drawn from across the research elements including the online survey with service providers, the views of naloxone coordinators, the in-depth interviews with service providers, programme beneficiaries and their families/carers in the four case study areas. A full analysis of the online survey results can be found in Appendix 5.

Training the trainers (TTT)

4.3 The TTT courses were generally delivered by either SDF staff or by local trainers. The latter tended to be used where the programme had been established for a longer period, for example in the Case Study A area where the course duration is one day instead of the customary two days. In another Case Study area (B) some staff training has also been delivered by Health Promotion staff for staff in services with people at risk so that they are able to administer naloxone in an emergency.

4.4 In the online survey most of the 186 respondents (71%) had taken part in a TTT course, with nearly all (96%) describing it as highly or fairly effective in equipping them to provide naloxone training, and nearly three quarters (70%) felt it was either fairly or highly effective in equipping them to supply naloxone.

4.5 This positive view of the TTT was borne out in interviews with service providers in the case study areas where the courses were widely seen as effective and covered the required aspects of the naloxone programme. A few people commented that the training did not always take account of participants' prior learning. For example, nurses could reasonably be expected to be acquainted with basic life support techniques. There was the suggestion that the course might therefore be shorter for some professionals. Staff in prisons who had received the training (again from SDF) felt that it was useful and covered all the main topics.

4.6 A few people mentioned that if they did not have the opportunity to make use of the training skills on a regular basis, they risked losing them. For some, who were not used to providing training, there was a lack of confidence about training in general.

"I feel confident if I had to use any of the skills from it. My other colleague who was trained but hasn't provided any training yet is anxious because she doesn't like needles; we will do it together. I'll do the needle part. If you don't start providing training straight away then you lose what you've learnt." (Group worker)

4.7 Those who were involved in supply were satisfied that the course covered the requirements of the PGD. One pharmacist wanted practical strategies for how to train people with problem drug use during brief interventions in the pharmacy.

Recruitment

4.8 In the online survey, the most effective recruitment mechanisms, identified as either fairly or highly effective, were word of mouth from peers (87%), direct targeting by professionals (87%), and word of mouth from professionals (86%). 71% felt that the THN programme is successful in engaging those most vulnerable to problem drug use.

4.9 Service users across the four case study areas reported that recruitment to the programme was mainly through contact with a range of professional staff from both statutory and voluntary sectors, including nurses, Community Addictions Team (CAT) staff, and voluntary sector drugs workers.

4.10 Thirteen interviewees had been in prison and had come into contact with the programme through treatment programmes - either ongoing or pre-release.

"Something called Phoenix at the prison. See, before you get out of prison, you have to do a release kind of thing and you go see Phoenix. It is voluntary but most people go. You see videos about getting out of prison and that. They mentioned naloxone, and that's how I got to know it." (Male, 30-40)

4.11 In prisons because the programme was voluntary, it was not always easy to recruit participants. Often prisoners would sign up for sessions but fail to turn up for them, choosing alternative activities such as gym sessions or paid work.

"They are easily distracted and quite short sighted" (Manager)

4.12 It was reported to the research team (both by a former prisoner and by a member of staff) that one prison had used a financial incentive (£1) to encourage prisoners to attend.^[21]

4.13 Factors that assist with effective recruitment to the programme in prisons included:

• information (posters, leaflets) being widely available in the halls, the Links Centre, the library;

"They pick up posters and leaflets, and ask 'what's naloxone?'. We tell them the group runs every Thursday." (Nurse)

• the 'positive' nature of the programme;

"The fact of learning CPR takes it away from a solely drug based programme. People have said it's useful in any setting." (EACS worker)

• staff clearly explaining the benefits of the programme to prisoners;
• encouragement from 'peers' to take part.

Service decliners

4.14 Eleven interviewees had been offered training but had declined. The reasons for this varied, but a common theme was that they had 'moved on' from drug using circles and therefore did not want to associate with, or be associated with these kind of environments. In these circumstances, it was generally seen as a good programme for other people who still use drugs.

"I haven't taken drugs in 10 years, it isn't for me, I'm not part of that scene anymore, I keep out of it and just get my prescription." (Female, 30-40)

If clients saw themselves as 'already on road to recovery', this could be seen as a reason not to take training and supply.

"'I don't run in those circles anymore', 'it won't happen to me, so I don't see a reason to do it' - that's the most common thing." (Group worker)

Training people who use drugs about naloxone

4.15 Over two-thirds (69%) of online respondents said they had trained service users in naloxone. A quarter (26%) of these have trained between one and ten service users, but 16% have trained between 51 and 100 service users and 12% have trained more than 100. If we extrapolate these figures to the overall number who have been trained (989), it gives an estimated figure of 585 who have trained service users of whom an estimated 152 have trained between one and ten people and 70 have trained over a hundred people.

4.16 Service providers in the survey consider 1:1 training as more effective for service users than group training. 68% described 1:1 training as highly effective, compared with 49% for group training. However, staff in prisons have a slight preference for group training and staff interviewed in prisons spoke about only using 1:1 training when the numbers turning up for training were too low.

4.17 There is a difference between the proportion of service providers who have trained service users in naloxone (69%) and those who have supplied naloxone to them (49%). This is potentially because there are many non-clinical staff in both the voluntary and statutory sectors who are not permitted to supply naloxone under the PGD.

4.18 Several interviewees across the four case study areas echoed the responses in the online survey in describing how their training of service users had evolved, with many moving from a group training model to a 1:1 training model. This allowed a more opportunistic approach to be adopted, where the training became less of a formal 'training' session and more of a brief intervention.

"Initially there was poor uptake, because you were asking chaotic and vulnerable people to come at a set time to sit for one and a half hours. Then we had a 'moment of sense'. We realised that the DVD was 'bells and whistle' but the important things to cover were: asking the client about their overdose experience; challenging the myths; how to recognise an overdose; dialing 999 and the reasons for this; emphasising that N was short acting and how to use it. It needed 15 - 20 minutes." (Nurse)

4.19 Rooting the training in the lived experience of the client was seen as a way of making the training relevant, for example asking the client sensitively if they had any personal experience of overdose or fatality.

4.20 Being able to offer naloxone training and supply was viewed as an essentially positive action. As well as providing the means to potentially save lives, there was value in the inclusion of practical skills such as basic CPR. This positivity was reinforced by the use of certificates. One worker recounted a home visit where the service user had mounted his certificate in a photo frame. Another interviewee echoed this.

"Most of the ones I've done lately want a supply. Some go and get it and come straight back to show you, it's good to say to them come back and show me I just want to see if the kit has changed or anything like that. Sometimes they are proud of showing you it, that they've gone and got it. There's a sense of achievement that they've done something. They get a certificate at the end, it's quite a nice certificate that they get and they want to keep it nice, they don't have a lot of achievements some of these people." (Support worker)

4.21 Several interviewees recommended the use of small incentives such as the availability of tea and coffee at the training session - especially group sessions.

4.22 Rather self evidently, training and supply was made more effective if there were the right number and type of staff available. One nurse in an addiction team felt that she was working in isolation and lacked the support of colleagues. She and some others highlighted the value of a naloxone 'champion' in the workplace.

4.23 Some pharmacies offered refresher training to service users and this was described as complementary to previous training, especially when it took the form of a brief intervention.

"Clients often say 'I've done that in jail', but we say we can do a refresher and give you the naloxone. It'll only take ten minutes." (Pharmacist)

Peer trainers^[22]

4.24 Three of the four case study areas use peer trainers and the views of those we interviewed across the areas were very similar. They all worked on a voluntary basis to train people in naloxone use. One group estimated that as a whole the peer trainers must have delivered around 1,000 hours of training (the national naloxone coordinator confirmed this figure as around 900 hours).They worked in partnership with professionals in CAT teams, pharmacies, and needle exchanges as well as in a range of outreach settings such as hostels. For some it was a kind of payback.

"Trying to put a wee bit back in the community. I was a drug user for years and all I did was take out of the community." (Male, 40-50)

4.25 As ex-users, they saw their contribution to the programme as being a credible conduit of information and awareness for people who use drugs who might not otherwise engage with services.

"When I was out there using - anyone in authority, you didn't talk to them." (Male, 40-50)

4.26 The trust they were able to engender was vital.

"With us being peers, we know where to touch. We get that trust." (Male, 40-50)

"When people are offered naloxone by CAT teams, nurses whatever, they're in the mindset of 'If I admit that I need this, I'm still in that company, it could jeopardise the prescription.' What we're doing is only a step to get people's confidence, to start engaging with services." (Male, 40-50)

4.27 They saw their role, in part, as dispelling myths about naloxone, not least its legal status.

"Drug users think it [naloxone] is good and should have happened years ago, but they say 'If I walk about with that the police will pull me'." (Female, 30-40)

4.28 They described a number of barriers that prevented people who use drugs from accessing naloxone. One of the key barriers was a perception that it reinforces the stereotype of that person having a problem with drug use. This could be overcome by explaining that the purpose of naloxone was for the benefit of other people.

"It takes the heat off them. You can see the barrier come down when you tell them it's not for them." (Male, 40-50)

4.29 One peer educator addressed the issue of the potential misuse of the naloxone kit for illegal drug use, and stated that this was now unlikely as injecting equipment was routinely available from needle exchanges.

4.30 They all agreed that being a peer educator was demanding and that, despite the benefits (such as increased confidence, contributing to their own recovery process), there was a 'natural wastage'. In one group which had initially recruited ten peer educators, there had been only three active members for a period of seven months.

Naloxone training: service users' views

4.31 Naloxone training had been received in both community and prison settings, with several people having experienced both. There appeared to be no perceived obstacles to this.

4.32 Training was voluntary in both contexts, but there were a few reports (from both a staff member and a former prisoner) of incentives being used in one prison.

4.33 Most interviewees recalled the key elements of the training: overdose awareness, the recovery position, basic life support techniques, calling the emergency services, naloxone administration (which indicates that it had been effective).

4.34 The length of the training in the community varied according to the setting, with reports ranging from 15 minutes to two hours. In particular, those who had been trained at a pharmacy tended to describe a briefer session, often undertaken in conjunction with the use of needle exchange facilities or picking up methadone.

4.35 Some had used the community based training as an informal 'refresher', having undergone initial training in a prison context.

"I forgot all about the palpitation pumps and how many it was, so the refreshers helped. The CPR - all of that helped. Finding out exactly how much to give." (Male, 40-50)

4.36 Both group training and 1:1 training sessions were reported, with each having pros and cons. Group training usually lasted longer and was sometimes seen as more enjoyable, although several mentioned the embarrassment factor of having to demonstrate CPR in front of their peers.

"You feel a bit silly when you get to use the wee dolly." (Female, 30-40)

4.37 When asked if the training could be improved, there were few suggestions, with most people feeling that it covered the necessary areas. Again, people emphasised the value of the 'refresher' training.

4.38 There was one interesting comment from a service user, who suggested that the training situation provided an ideal setting for both provider and user to learn something.

"The pharmacist could learn off me! He's never been in a house where there's an overdose." (Male, 30-40)

Supplying naloxone

4.39 Staff interviewed in the four case study areas identified a number of facilitators that supported the effective delivery of supply of naloxone to people who use drugs. Proximity of time and place between training and supply was a key factor highlighted by several people. Where this was the case, most people would take a kit. On the other hand, where the client needed to go to a separate venue to pick up a supply, this often meant that the supply was not in fact obtained.

4.40 Sometimes the intervention was described as being at the 'wrong' time, for example when service users simply wanted to pick up injecting equipment.

"At the needle exchange, people are desperate just to use. People here are at crisis point." (Nurse)

4.41 There were comments in some Health Boards about the lack of dispensing pharmacies for naloxone, and the lack of supply in these areas was seen as an obstacle to service users being able to access supplies.

4.42 Naloxone supplies to prisoners who had received training were made on liberation. The naloxone kit was placed in the 'valuable property', usually by nursing staff, and issued by reception staff to prisoners on leaving the prison. This was seen as generally working well, and although some initial difficulties were described with the process, these are now either resolved or in the process of being resolved.

Naloxone supply: service users' views

4.43 The majority of interviewees who were trained by statutory services reported receiving the THN kit on the same day, and mostly at the same place and time as the training. This was seen as a logical step.

"Yes, at that time there was a doctor came in to sign it off there and then, so we got it straight after training. So we didnae need to go to the chemist and pick it up." (Female, 20-30)

4.44 Those trained by voluntary sector agencies however reported that they often had to go to a pharmacy for the supply of the kit which was separate to where they had been trained.

4.45 Others reported that they had taken the kit on release from prison. This was as part of the prisoner's 'property' collected on release. One former prisoner mentioned that his reason for taking the kit was not for his own use, but for potential use in an emergency that involved others.

"I wanted to take it even though I was drug free. I still see IV drug users in company. It could be a life saver." (Female, 30-40)

4.46 In some more rural areas there were issues relating to access to supplies of the kit particularly where not all areas had community pharmacies who supply naloxone. Both service users and staff in one rural area recognised that this lack of access to supply of kits could be an issue.

Carrying the kit

4.47 Views varied as to whether the kit was something to carry routinely or not. Some made a point of carrying it on them.

"Always. I carry it everywhere, no matter what. It's always on me, no matter what. You could be walking past a close, a tunnel, a toilet and some [person] could be lying there." (Male, 20-30)

4.48 Others preferred to keep it at home.

"I just keep it in the house, in a drawer in the house... I'm feart I'll get stopped by the police and they'll take it off me. It's happened to a couple of my pals." (Male, 40-50)

4.49 Potential repercussions if stopped by the police were mentioned by several interviewees. There were a number of accounts of problems with police interventions, including one where four service users who had just completed a naloxone training course, and were having a cigarette outside the training venue, were searched by the police. Several interviewees reported that there was a risk that carrying the kit simply reinforced an already negative stereotype of the "drug user".

"I don't carry it because of the police. If the police pull you, and you've got a syringe (even if it's naloxone), they'll keep you for longer and strip search you. It's humiliating. If your face is known, you're targeted." (Male, 30-40)

4.50 Some reported a pragmatic approach to carrying the kit, making a decision in relation to planned drug taking activities.

"If I'm going to a jagging den, I ask if there's naloxone in the house. If there's not, I bring it with me." (Male, 30-40)

4.51 A few interviewees saw themselves as an informal community resource. One man had advertised on social media the fact that he had naloxone. One woman was active in letting others know locally that she had a kit available in the event of an overdose.

"Because I bide in the middle of the town centre, and there's a lot of people round about me still doing it. I've told every one of them of them - anyone overdoses, just run and get me, because I can get to them quicker than an ambulance can." (Female, 30-40)

Using the kit

4.52 Most service users felt that the kit came in an acceptable form, and was alright to have as part of their possessions. There were no specific improvements that received majority support. Some found it easy to open, while others found it tricky. Some liked the bright yellow packaging as you could clearly identify it, while others found it too visible and preferred the clear packaging. There was general agreement that it was more practical for women to keep it unobtrusively in a handbag, while for men, this was more difficult.

4.53 Significantly, there were very few reports of the kit being misused, and the majority of interviewees expressed the view that having access to the kit did not encourage drug use. Unlike the concern expressed in the research for the Welsh demonstrator programme cited in the literature review^[23] there was no reporting of the fear that multiple doses might result in major withdrawal.

4.54 All service users who had received training and THN kit were asked if they had had occasion to use the kit. 15 out of 37 service users had used the kit - three on more than one occasion. Most accounts were about usage in a flat or house. The following account is typical.

"I just saved a boy about two weeks ago with naloxone. It was scary. I wasn't there when he ODd, but I walked into the house and the lassie was gouching and her boyfriend was lying on the floor - blue - and she didn't even know he'd ODd. So if I hadn't turned up when I turned up, he wouldn't be here…………… I put him in the recovery position and gave him naloxone and he started breathing. But then he went back into the OD, so I had to wait a couple of minutes and give him another, and then I had to give him another one, and that's when he came out of it. By the time the ambulance came, he was fine. The ambulance guy said 'he was lucky you were here'." (Male, 20-30)

4.55 A few were in public spaces.

"There was an OD outside the toilet in [xxxxx] Street. The person didn't know what to do. He had been going to use heroin. I checked the airways, he wasn't breathing. I used [a dose] and someone called the ambulance. The person came round. There was no hassle from the police." (Male, 20-30)

4.56 Despite this account describing a lack of police harassment, the reality of 'intrusive' enquiries from the police was a common theme amongst service users across all four areas. One person gave a sad but realistic description of what often happens when someone overdoses in a residential property, and the tenant tries to remove the evidence.

"From all the stories I've heard of people overdosing and that, there seems to be a lot of people trying to hide bodies. It's horrible. They locked them in a cupboard or put them outside, just threw them out." (Male, 20-30)

4.57 This gives rise to a reluctance to call the emergency services because of the likelihood of automatic police involvement.

"Cos if you're in and someone takes an overdose in the house and you're the only one that's there, the police charge you because you could have given them that hit. So that's how some people don't call the police, or else they'll call an ambulance and do a bunk from the house." (Male, 40-50)

4.58 A few interviewees thought that the attitudes of the police needed to change as they can be a barrier to people seeking help. This point was also illustrated by a pharmacist who emphasised when training service users that they should be careful about how they describe the emergency situation (to avoid the police being called).

"Phone an ambulance and say it's an unconscious person. Don't mention naloxone or overdose." (Pharmacist)

4.59 On the other hand using naloxone was seen as a practical way to avoid police enquiries in these kinds of situations, as well as being a life saving drug.

"It gives you the power back to save someone's life. If someone dies in the house, it's hard to explain away. It's saved millions of questions from the police." (Male, 30-40)

Training and supplying families and carers

4.60 Nearly a third (29%) of service providers in the online survey have trained family members/carers in naloxone. 56% of these said they have trained between one and five family members/carers. This took place in NHS clinics (46%), voluntary sector agencies (38%) and in families' homes (27%).

4.61 68% thought that families feel reassured knowing they could help prevent a fatal overdose.

4.62 The vast majority of service provider interviewees in the four case study areas acknowledged the difficulty of engaging family members and friends. This was exacerbated by the fact that people who use drugs often had broken inter-personal relationships and chaotic lives, and might be reluctant to engage with their own families. Some residential staff also pointed out that client confidentiality sometimes mitigated against family involvement.

"It's difficult to tie down a typical family member. Some are horrified and want nothing to do with it. Others are there for their partner or child." (Group worker)

4.63 There was common agreement amongst professionals about the need for legislative change to naloxone to enable family members to be supplied with naloxone without the person who uses drugs' consent. In Glasgow, this had been highlighted in a campaign called 'Lisa's petition' established by a third sector organisation. A pharmacist from another area echoed this sentiment.

"I've had parents in tears in the shop asking 'what can I do?'. It's a drug that anyone can administer in a life-saving situation, but it's not available to anyone. They can put defibrillators in shopping malls and adrenaline into schools, but not naloxone!" (Pharmacist)

4.64 Staff working in prisons who were interviewed generally had very little contact with families, although this was more frequent in one prison. In one prison, there were plans to deliver drug awareness sessions (including naloxone) at the Family Hub Centre which all visitors go through prior to a prison visit. In another prison, healthcare staff encouraged prisoners to ask their families to access the training in the community, but had no direct contact with them.

Families' experience of training

4.65 The main reason for taking part in the training, expressed by all eight family members we interviewed, was a concern for their child, and to acquire some peace of mind in the event of a possible overdose.

"It's a prevention method. If he [her son] has an overdose that is something I can give him while I'm waiting on the ambulance coming." (Female, 40-50)

4.66 The training had helped them to learn about CPR, the signs of overdose, and how to use naloxone. One mother had learnt new information about overdose.

"Just that with [son] using maybe two or three different substances, there is more chance of him having an overdose, rather than just one substance. If he does happen to change supplier, it could happen at any time, just a bit more information for myself." (Female, 40-50)

4.67 Two of them said that naloxone was easier to use than they had expected. Three of them said that the CPR dimension was a refresher for them as they already had the basic knowledge.

4.68 There were no suggested improvements to the training, but one person said a wallet sized card containing the essential information about naloxone administration would be useful.

Families' experience of supply

4.69 Three of the interviewees did not have a kit because their sons had refused to go to the chemist with them and give permission for them to pick up a kit. Two had just been trained and were happy with the kit, and two others had been supplied with a kit a number of years previously.

4.70 The three mothers interviewed in one area were very involved in 'Lisa's petition', a campaign to change the POM status of naloxone to make it available to family members without requiring the consent of the person who uses drugs. Those who had received kits said they were confident to use them. No changes to the design of the kit were proposed. None of those interviewed had used their kit.

Support materials

4.71 Service providers who responded to the online survey had mixed views about the effectiveness of naloxone support materials. 72% described materials for professionals as fairly or highly effective. 61% described the national naloxone website (www.naloxone.org.uk) as fairly or highly effective. The figures for materials produced for families and carers (50%) and peers and friends (48%) were lower. However, notable proportions of respondents felt unable to comment on these materials.

Partnership working

4.72 Service providers in the online survey were generally positive about partnership working in their area. Across all respondents in the online survey 79% felt that partnership working in their Health Board area is fairly or highly effective.

4.73 A lesser proportion, 50%, felt that partnership working at national level is fairly or highly effective, but most of the remainder (44%) felt unable to comment so this lower figure may reflect a general lack of awareness of what is happening at national level.

4.74 The case study evidence provided many concrete examples of practical cross-sectoral working. In Case Study B, there was close communication between a third sector agency and the local branch of a pharmacy, with for example frequent telephone discussions about mutual clients. In Case Study A, NHS nurses provided an 'in-reach' service to clients at a third sector residential facility.

4.75 A few interviewees pointed out that partnership working required shared strategic aims and in some situations this was not always thought to be the case.

4.76 In prisons the key partnership within the THN programme was between SPS and the NHS, following the transfer of responsibility for healthcare in prisons from SPS to the NHS in November 2011.

4.77 In two prisons, staff reported that this partnership was working effectively. One manager said that under the previous arrangements, SPS had a contract with a third sector contractor for the delivery of the Enhanced Addiction Casework Service (EACS), which was described as 'restrictive', with a lot of time spent on 'micro managing anomalies in the contract'. Since the transfer, this had become less restrictive, more needs based, and prisoner focused. Under present arrangements they had less direct control over the numbers trained, but this was not seen as a problem. Frontline staff reported strong joint working between nursing and EACS staff.

4.78 In one prison, there had been problems with the NHS not being able to release staff to run naloxone sessions due to resource constraints.

Strategic and policy support

4.79 Views on the effectiveness of strategic and policy support for the THN programme were quite mixed, with a significant proportion of community respondents (40%) in the online survey unable to comment on the national level strategic and policy support. These are set out in Table 4.1 below.

4.80 Respondents felt that the most effective support came at Health Board and ADP level (which may be because these are the levels they felt more able to comment on). Service providers in prisons who responded were more positive than community respondents for most of the areas of strategic and policy support questioned (although the sample size from these respondents was fairly small at n=24).

Table 4.1: Perceptions of strategic and policy support^[24]

	Community respondents (n = 144)		Prison respondents (n = 24)		Total (n = 168)
	Highly or fairly effective	Don't know	Highly or fairly effective	Don't know	Highly or fairly effective	Don't know
Strategic and policy support within the Scottish Government	53% (n=145)	40%	63%	33%	54% (n=169)	39%
Strategic and policy support within your NHS Health Board	68%	25%	75%	17%	69%	24%
Strategic and policy support within your ADP	71%	19%	71%	21%	71%	19%
Strategic and policy support within Scottish Prisons	29%	66%	79%	13%	36%	58%
Strategic and policy support within SDF	54%	40%	67%	29%	57%	39%

Management and accountability

4.81 The four case study areas illustrated some of the differences in the local management and accountability that the survey with naloxone coordinators had highlighted. Three of the four areas have a steering group but Case study C does not. In this last area it was recognised by those interviewed that it might have been helpful to have one but its management and accountability is undertaken by the naloxone coordinator who reports to the ADPs. The composition of the steering group in the other three areas is varied with one (Case study A) being predominantly NHS focused plus representation from prisons and peer trainers; another (Case study B) having a varied range of partners involved including a GP (the only steering group of the three to have GP involvement), the third sector, police and ambulance service. The third (Case study D) has some partners represented but is not as comprehensive as Case study B.

Summary of main points

4.82 The training of staff and peer trainers was seen as effective in terms of giving people the knowledge, skills and confidence they require to offer naloxone training. Some nurses felt that the course could have been tailored more to take account of their prior knowledge. There may be some need for refresher training for those who have not used the skills acquired after training.

4.83 In terms of supplying the kits it is clear that this works best when there is proximity of time and place between training and supply. Improving the consistency of supplies available through community pharmacies, particularly in rural areas, could increase access to naloxone. Some service users see themselves as being able help others in their community by publicising the fact they hold a supply of naloxone. There is interest expressed in seeing more people being allowed to hold supplies of naloxone including family members.