(Are) The United Nations on Drugs



(Are) The United Nations on Drugs.


 United Nations have exerted a unique element of drug control globally since 1909. So what has that ‘control’ really achieved over  that century+

In an extension to the World Drug Report (chapter 2) a paper entitled ‘A CENTURY OF INTERNATIONAL DRUG CONTROL’ the opening statement read…..



“For those who doubt the effectiveness of drug control, consider this. In 1906, 25 million people were using opium in the world (1.5% of the world population) compared with 16.5 opiate users today (0.25% of the world population). In 1906/07, the world produced around 41,000 tons of opium – five times the global level of illicit opium production in 2008. While opium used to be produced in a huge belt, stretching from China to Indochina, Burma, India, Persia, Turkey and the Balkan countries, the illegal production of opium is now concentrated in Afghanistan (92%)”


The illegal production of opium is indeed concentrated in Afghanistan a country and no longer overseen by the Taliban who regulated and exerted extreme measures to ensure quality control and a consistency in supply. Instead it is now regulated by the US of A.  No more quality control, no reduction in supply, other than a complete drought during take over which resulted in a sharp spike in drug related deaths during 2008-9, and obviously no respect for HR principles in that not one ounce of sense passed over under tupe law to ensure consistency.


Oh yeah, they were meant to be ending the war on drugs silly me?


Obviously the new contract / agenda, (not available via Freedom Of Information Act for some unknown reason) had a radical ‘hidden’ agenda,’Operation Blatantly Obvious’ based loosely on the 1996 Nicaraguan agenda and legislation but without the ‘Contra’versial partnership for a more complex service provision that covers all angles.  As it stands nothing changed. It still rages on ‘under new management’


In 1906, the ‘huge’ belt that is mentioned including China, who incidentally were responsible for the first anti-opium edict. Emperor Yung Ching, imposed severe punishment on any sellers or opium business traders back in 1729. Prohibition proving itself a dismal failure even back then it would seem. Yes China, were, unwillingly, subcontracted to India due to the increased demand for opium. Which incidentally, or coincidently, increased significantly when the British occupied India, isn’t history such a wonderful thing?

Quote from the ‘Opium Monopoly’ – ‘’China was powerless to protect herself from this menace, either by protests or prohibition. And as more and more of the drug was smuggled in, and more and more of the people became victims of the habit, the Chinese finally had a tea-party, very much like our Boston Tea Party, but less successful in outcome. In 1839, in spite of the fact that opium smoking is an easy habit to acquire and had been extensively encouraged, the British traders found themselves with 20,000 chests of unsold opium on their store-ships, just below Canton. The Chinese had repeatedly appealed to the British Government to stop these imports, but the British Government had turned a persistently deaf ear. Therefore the Emperor determined to deal with the matter on his own account. He sent a powerful official named Lin to attend to it, and Lin had a sort of Boston Tea Party, as we have said, and destroyed some twenty thousand chests of opium in a very drastic way. Mr. H. Wells Williams describes it thus: “The opium was destroyed in the most thorough manner, by mixing it in parcels Of 200 chests, in trenches, with lime and salt water, and then drawing off the contents into an adjacent creek at low tide.”


This off course pissed our British contingent off and again, coincidently,  as with all envoys in this kind of interaction, poor Lin was found two weeks later propped up against a tree with his favourite book and a  gunshot to the back of the head,  8cal, in his hand was a 9mm. The obvious analysis was suicide, so, so,  sad.  Or was it a 1ml in his hand and over  1gal of opiates in his system, I forget……

…..and digress…..

Anyway this was to be the start of the biggest Opium war to date, led by, and indeed won by our proud little firm of international dealers, sorry, British merchant bank, er sorry,  sailors  who steamed up the Yangtse, demanding the Chinese give them their gear back and compensation for the damaged goods. At the same time opening up the shipping ports to continue trading as per usual. God save the Queen?



India at this point just kicked back and ensured production was consistent and steady to meet demands, to supply, to meet demands.


Then, 15 years later,  as sales and demand again grew, more outlets were needed so our good old sales people put in the proverbial boot , (no pun intended) resulting in a second war, smothered under religion….”Great Britain, the first Christian power, really waged this war against the pagan monarch who had only endeavoured to put down a vice harmful to his people. The war was looked upon in this light by the Chinese; it will always be so looked upon by the candid historian, and known as the Opium War.” (Middle Kingdom)

In 1917, China was practically free from the native-grown drug, and foreign importation had practically ended. The final years of native-grown poppy indulgence was enjoyed only be upper classes while the lower working classes were subject to sever punishment.

So back to the initial statement in the original topic. Restriction to India of the restriction of opium growth was a natural occurrence, and restriction in production and sales was because the Chinese were no longer needed to smuggle or market the substance. The ports along the Yangtse were now operating under International law and manned by concessions in each port of  German, Austrian, British, French, Russian, mainly but not exclusively.  The United Nations were still an unfertilized egg waiting for some wanker to spawn them with a one off, lucky? shot.


My last edition to this prequel to the actual birth and report to follow is quite basic and, in my opinion blatantly obvious.  The declaration that there are far less opioid uses globally, do we really need to put our answers on a postcard here? I personally, am going to go out on a limb here and take a wild guess that it could have something to do with the elements of control, or numerous different attempts at control,  exerted over the last 110 years, by enforcers who feel the need to control in the first place. Yep, think I’m safe in saying the numbers are decreasing because….

WE ARE DYING OUT HERE?….Just saying…….But hey I could be wrong?



Implementing local Take Home Naloxone Programs (UK)

cropped-eye_drops_water.jpgOn 19th February, Public Health England released guidelines aimed at local authorities for Take Home Naloxone programs. This is aimed at following the recommendations in the letter from Department of Health (Jane Ellison) to Advisory Council for the Misuse of Drugs chair Les Iverson where there was a date for the National implementation for Naloxone programs, and recommendations into the preparation for the programs to be initiated on 1st October, 2015. Although the general consensus around this date is that it is too far in the future and leaves to much scope for a further increase in drug related deaths, this date is the one that NAG (Naloxone Action Group) England are now holding providers to as a set deadline. Here are a few ways in which you can inform / support your local authorities to ensure that this is being implemented locally in time to meet the 2015 deadline.

Follow hyperlink for copy of guidelines: http://www.nta.nhs.uk/uploads/take-home-naloxone-for-opioid-overdose-feb-2015.pdf


UK Law.

Like all medicines in the UK, naloxone sale and supply is regulated under the Medicines Act of 1968. This act brought together most of the previous legislation on the regulation of medicines but also introduced some new legal provisions for the control of medicines. When thinking about the regulation of medicines, it’s important to recognise that medicines (broadly) fall into one of four categories;

  • GSL. General Sales List Medicines sold or supplied direct to the public in an unopened manufacturer’s pack from any lockable premises
  • P. Pharmacy Medicines sold or supplied from registered premises by, or under the supervision of a pharmacist
  • POM. Prescription Only Medicines sold or supplied to named patients by prescription. Applies to all injectable preparations, including Naloxone
  • POM (CD). Controlled Drugs

As stated above, injectable naloxone is a POM and can therefore only be SUPPLIED to a person identified as ‘at risk’ of potential future opiate related overdose. It can be supplied to the friends/loved ones of those identified as at risk, but only with the written consent from the person for whom it’s to be supplied.

Who can administer naloxone?

Anyone can administer naloxone for the purpose of saving a life. In November 2005 naloxone was added to the list of injectable drugs in Article 7 of the Medicines Act, this is the part of the act that covers drugs like insulin for diabetics (and adrenaline, atropine, snake anti-venom etc).

Who can supply naloxone?

Naloxone can be prescribed by any medical doctor, but can also be prescribed by some other registered medical staff using a Patient Group Direction (PGD). This means that naloxone can be given out via drug projects that don’t necessarily have a doctor on their staff.

(Taken from Scottish drugs forum Naloxone: http://www.naloxone.org.uk/)

This would mean that in order to get Naloxone out into the community there needs to be a prescription given to an individual who has been ‘catagorised’ as high risk. This could mean treatment naive community members, those still in treatment, those leaving treatment, including residential rehab, prison leavers, in light, anyone receiving any kind of opioid medication, on prescription.

At this particular moment in time, following a freedom of information request carried out by National Needle Exchange Forum, Release and NAG Engand members, the evidence would suggest that 1 out of every 3 Health and Wellbeing boards are supplying naloxone. Considering the high level of drug related deaths Nationally in 2013. This seems to be a small amount for such a major public health issue.

In light of this information, there are a number of things you can do locally to help push this program forward and to make sure that it is firmly on the agenda in your area in line with the guidelines.

  • take-home-naloxone Identify local champions: Local authorities will be looking to identify local champions. This could be you, or it could be someone who is sympathetic to the need for Take Home Naloxone programs. If your local MP signed the Early day motion 445 – NALOXONE AVAILABILITY – UK then you may well have you local champion there, sympathetic GP’s, Pharmacists, local recovery / harm reduction groups, etc. Identify who your champion is and encourage them to engage with Naloxone Action Group (NAG) This can be done via the NAG England website or via the facebook forum page. This will enure that they have all the support they may need when engaging with any local authority agents on any level.

website: https://nagengland.wordpress.com/

facebook: https://www.facebook.com/groups/1455313511394512/?fref=ts

  • Organise an initial ‘informing the managers’ or ‘train the trainer’ session: While this is being done by local authorities, you could be raising awareness of your plan of action to disseminate information into your community. If you are planning local train the trainer sessions or have been asked by your local authorities who might be delivering the training, but are unsure how to go about it, please contact me at drugactivist@gmail.com and I will direct you to your area representative. You can then pass relevant information over to local authorities and support them in initiating the training.
  • Consider who will receive Naloxone supplies, and how, users and carers, hostels and pharmacies, etc: The aim here is to have Naloxone freely available in all providers that come in contact with high risk individuals, and eventually, being ambitious, over the counter. However, the first step would be identifying key areas where there are high risk individuals, treatment services, hostels and prisons, might be a good start. The local authorities should be more that aware of where there is an immediate need. You may have to prioritise here as a first step and decide where there is the most benefit to be had. Needle exchange programs, would be an ideal starting point.
  • Consider who will pay for Naloxone supplies in different areas: Commissioning for such programs sits firmly with Department of Health as the overseers of Public Health but on a local level responsibility sits with the CCG (clinical commissioning groups) following a transfer of responsibilities through localism. To find out your local CCG contact details: NHS England » CCG Directory Also as a matter of interest here Frontier Medical Group are now the official distributor of Prenoxad / Naloxone kits for Martindale Pharma so they will be the single point of contact for provision of supplies.
  • Agree how you will re-supply people when Naloxone is used or it expires, and who will pay. Will you have a system that flags up appraoching expiry dates to keyworkers, pharmacies, etc: As with any form of medication there needs to be a medication management database for monitoring purposes. This would need to monitor all needs and results pertaining to Naloxone provision. How many kits were given, when given, adverse effects of medication, etc. Once the basics for this are done then it would need to be reviewed to see how to monitor a case by case study of each individual involved in the program. All input would need to be evidence based and precise in it’s records. Medication regimens for every naloxone reciever need to be monitored and also all different naloxone products of there is to be intranasal available as well as injectable, etc. Most of this should be in place for already existing medications in the community and it would simply be a matter of adding Naloxone to the list of medications already monitored. Another thing that may need to be discussed here is the need to expand the monitoring to co-morbid conditions and socioeconomic status, substance use, homelessness, chronic health conditions, employment status, etc. As already stated there should already be a monitoring system in pace which could provide the basis on which to ad the information needed regarding Naloxone provision. This action lay with local authorities primarily so does not hold any weight on what you might be forming as a part of your action plan to offer support locally.
  • Hold regular meetings for Naloxone champions – including people who use drugs – to encourage progress, discuss barriers of concerns, and learn from each other: This is already happening in a number of areas so it is simply a matter of inviting the local authorities to come along and join the already existing platform that you have provided. If there is no platform locally, you can create one in the form of a local Harm Reduction Cafe where local provision and action plans can be discussed and implimented. All you need to set one up is available on the website. This should be publicised and openly supported / attended by all providers who deal in the care of those considered at risk in the community. Also as stated attended by local service user reps, groups, and people who are currently using substances.
  • Explore the products and prices available, speaking to the local pharmaceutical representative,  and decide together with local providers which to purchase: At this moment in time in the UK there is only one licensed product available and that is Prenoxad Injection This sight gives you all the relevant information around this particular product. The main suppliers of this product as stated before are Frontier Medical Group A kit costs £18 and there is an agreement in the contract with the pharmaceutical company that this price will stand unchanged for at least the first three years of the contract. It has been advised that two kits are complimentary to the needs of those who would be accessing services for it. One to carry on their person and one to leave in home environment. So if you can find out the local statistics pertaining to injecting drug users then you will effectively be able to get a rough estimate of how much is needed to ensure enough kits are bought in to meet the needs of your user community. There may be an online needs assessment for local IV users on your local authority webpage that can help you with this.
  • Complete the paperwork and processes of a PGD, working with the local CCG and director of public health as appropriate:A PGD is a written agreement that in the case of naloxone allows nurses or pharmacists to distribute the drug to people at risk of overdose. It’s important to note that a PGD is only related to the supply of the drug and has nothing to do with administration (as we’ve stated above anyone can legally administer naloxone to save a life). A PGD should contain the following information:
    • The name of the business to which the direction applies
    • The date the PGD comes into force and the date it expires
    • A description of the medicine(s) to which the direction applies
    • The class of health professionals able to supply or administer the medicine (as named individuals)
    • Signature of a doctor or dentist, as appropriate, and a pharmacist
    • Signature by a representative of an appropriate health organisation
    • The clinical condition to which the direction applies
    • A description of those patients excluded from treatment under the direction (if applicable)
    • A description of the circumstances in which further advice should be sought from a doctor and the arrangements for referral
    • Details of the appropriate dosage and maximum total dosage, quantity, pharmaceutical form and strength, route and frequency of administration, and minimum or maximum period over which the medicine should be administered. Legal status of the drug should also be indicated
    • Relevant warnings, including potential adverse reactions
    • Details of any necessary follow-up action and the circumstances
    • A statement of records to be kept for audit purposes

Sample PGD: http://www.naloxone.org.uk/images/pdf/pgd%20naloxone%20approved%20apr%202011.pdf

  • Inform and liaise with police, local coroners, ambulance service lead, hostel managers and pharmacies: This one is also something that is best coming from local authorities as experience tells us that correspondence is less than positive when coming from action groups. However if you have been identified as local champion then it might be possible to be cc-d in on any local correspondence or contact to keep you up to date with progress and to put you in a position to inform the local action group of that progress. By all accounts local police should be trained and equipped and it is surprising how many police do not know what Naloxone is, following a number of ‘stop and question’ scenarios I was asked a number of questions surrounding the medication but when I suggested training options they never came to anything. Lcal coroners could be a valuable asset with regards to them being able to give first hand statistical data on causes of death, although this is jaded as cause of death isn’t always recorded correctly. This is for the benefit of the family afterwards. And also there are times when the actual cause of death cannot be attributed to one single underlying cause. This can at times work in favour of some research but in this particular case it does not. Local ambulance crews should be aware of the fact that naloxone is locally available and also on a national scale this needs to be addressed as when you call in a situation, at present, the best way to get a response is to not mention drugs at all and if you do mention that you are equipped and trained you are told under no circumstances to administer. Hostel managers should be a priority with regards to involvement in the program as they are involved in the care and support of some of the more vulnerable in the community. There are number of areas where hostels were approached first for training in preparation. This can also be something that can be carried out by local action groups in support.
  • Purchase the naloxone kits and make the necessary arrangements for stocking and distributing them, and for re-supply when naloxone has been used or expired:  The arrangements for re-supply should be straight forward, all services in possession of naloxone should encourage those who lose, use or have a kit that expires to come in to get a kit  replaced. The ideal place for distribution would be Needle exchanges, pharmacies and prison healthcare. Any other places that you may consider should be suggested at any meetings with local authorities.
  • Provide training for all drug keyworkers, all opioid substitution therapy (OST) prescriber’s locally, dispensing pharmacists, local service user groups, all of whom can contribute to the onward dissemination of information:   This target has already been partially reached in a number of places and training has or is being done already. This is where local service user groups come into their own and provide an invaluable part of the localised agenda. If you have been on point with the call to arms then you will already have been trained locally and can then put yourself or your group forward to disseminate the training and relevant information around naloxone, basic life support and administration, individual certificated training can be done online at SMMGP – Substance Misuse Management in General Practice website. There are also local reps strategically placed nationally to deliver training, if you contact me at drugactivist@gmail.com then I can direct you towards your local train the trainer.
  • Arrange for training to be provided to people who use drugs, patients and clients, and their families and friends, Consider who is best placed to deliver this training. Offer this training to as many people as possible:  It stands to reason that those who are in the best position to cascade the training out to their communities are those out there on the frontline, this again would fall into the responsibilities of the local service users groups. If your group is not trained then then I wold suggest that you look into arranging training and put this in place. It may hold up the process or put the partnership options that are presenting into the hands of someone else. Once trained you are then in a position to offer yourselves as local trainers and pass this onto everyone you meet who has an interest. And id you are anything like me, even even those that don’t.
  • Consider whether and how you will record the numbers of kits dispensed, and report the number of times naloxone was used: Part of the initial training and something that is also advocated for in an overdose situation is that an ambulance is always called. This is to reduce risk of the individual slipping back into an overdose as the naloxone wears off after 20-40 minutes. The research around this does state that the effects of street heroin is not much more but the risk is still relevant as due to prohibitive laws surrounding illicit heroin there is no quality control, etc.   There are however times when they may not be called,  a formula may need to be discussed as to how to monitor this, The number of kits dispensed should be easily monitored and most uses, hopefully, recorded by ambulance call outs, etc. This message is something that you can carry out into your communities. We have fought long and hard to get this far, in order for it to stay as part of service provision then we need to ensure that we are responsible, sensible and accountable for our part in the program which includes carrying the message that supports those who support us in maintaining the program at a local level.


We could instantly reduce the number of overdose deaths if this medicine were more widely available

Please circulate where approriate, help us to save lives.

Naloxone Action Group - England

What do we do with a medicine that prevents certain death for people with a particular condition—and is safe, cheap, and easy to administer?

  1. Immediately make it accessible to those who can administer it when such a life-or-death situation arises.
  2. Make it available to no one except doctors and emergency room workers.
  3. Endlessly debate the particulars of how and when it should be widely introduced.

If you picked number one, that would seem to be a reasonable choice. Unfortunately, it would also be incorrect. With few exceptions, answers two or three apply in the vast majority of the world when it comes to the medicine naloxone.

Overdose remains a leading cause of death among people who use drugs, particularly those who inject. Increasing the availability and accessibility of naloxone would reduce these deaths overnight.

View original post 443 more words


(To whom it may concern),

I am contacting you in relation to a current national campaign to reduce drug related deaths in England. In light of the recent 32% rise in drug related deaths bringing the statistical data of those dying from overdose involving opioid substances in 2013 to a staggering 765 deaths, each one preventable.

Please find attached below a brief timeline of Naloxone from it’s inception up until present .


As you will see there are a number of periods where there has been open endorsement from a number of sources here in the UK. These endorsements have been made by:

Professor John Strang in the British Medical Journal (1996).
ACMD (Advisory Council for the Misuse of Drugs) (2000) (2012)
UK Clinical Guidelines (2007)
NTA (National Treatment Agency) (2007) (2009)
MRC (Medical Research Council) (2008)

The department of health chairperson Jane Ellison sent a letter, in July of last year, to the ACMD giving clear direction as to a date for commencement of National Naloxone program from October 2015….


This letter lays out a clear and direct plan of action which advocates for training and any other preparations to be supported ‘prior’ to the date given for roll out and was a direct result of the MHRA survey which returned an overwhelming show of support for the provision of Naloxone in the community.

I feel that a delay until October 2015 is irrational given the evidence of support given and believe that this delay warrants a judicial review based on the evidence collated globally and also from the National programs in both Scotland and Wales where take home programs have had a positive effect on th statistics surrounding drug related deaths. I also feel that this delay is a serious breach of human rights in that every human being has the right to access life saving medication and the right to live. This delay has the potential to interfere with the right to life and also the right to a family life.

Given the case that I hereby put forward for direct and immediate action towards implementation of Take Home Naloxone programs nationally. I would be grateful if you could reply to my concerns by:

A: Informing of what is currently happening locally to put this program in place
B: Informing me of the reasons for delay in implementing a local program.

I look forward to further correspondence with you regarding this issue.

Yours sincerely,


 1961:  Naloxone was first cited by Jack Fishman and researched by Harold Blumberg in 1961. The synthesis stated that although naloxone was not the first and only opioid antagonist it was however the first that did not produce analgesic qualities. The synthesis also explained other qualities of naloxone stating that it was indeed a medical breakthrough with regards to the reversal of respiratory depression in all synthetic and natural opioid related substances. It was also useful in coma situations where the cause was of unknown origin to eliminate whether there was opioid presence that had induced the coma like state. It was used on new born babies following the administration of opioid related medication to mothers during pregnancy. Nalorphine preceded Naloxone but after further research was found to cause analgesia and in higher doses hallucinations. Naloxone was found to be the ideal balance between agonist and antagonist and prove to be the only pure agonist which made it the more effective and preferred of all previous researched chemicals.

1962: The previous mentioned document was an abstract in Federation proceedings and the first full report was later released by a group working for Sankyo company in Japan in the Science citation index. Sankyo applied for the British patent for Naloxone in March 1962 and it was awarded in October 1963. The early delays in patent were attributed to the fact that Naloxone was of more interest in the academic field than it was in the commercial one in the earlier years of it’s beginnings. Also at this time the main interest of researchers and scientists was to research and produce analgesics.

1966: Blumberg released a full paper on the qualities and uses of Naloxone which was later to become the centre of the field of endogenous opioids where Naloxone became one of the key components and was heavily relied on for its qualities. Throughout the early 1970’s both Fishman and Blumberg’s research and related work on and around Naloxone focused primarily on the clinical applications of the medicine as did most of those involved in the researching and practice of medical compounds.

1971: The FDA (Food and Drug Administration) in the USA licenced Naloxone stating that access to naloxone would require a prescription from an authorized health care provider. Some physicians were reluctant to prescribe the medication to suspected opioid-misusing patients. At least one legal analysis, by Burris et al, concluded that health care providers ”do not act outside state and federal regulations in prescribing naloxone to their at-risk patients and the risks of liability are low and commensurate with those generally associated with providing health care” The Good Samaritan laws in a number of states in America provides legal protection to physicians for prescribing the medication and also to those in the community carrying and administering the medication.

1973: A patent was issued in 1973 for an analgesic combination which comprised of an orally inactive dose of naloxone and an orally active strong analgesic. Naloxone was also found to reduce obesity in further studies on animals, this research is still ongoing to date. Towards the end of the 1970’s the importance of Naloxone as one of the most relevant medicinal breakthroughs in the research of endogenous opioids and further qualities within the medical world was beginning to gain recognition.

1982: Jack Fishman and Harold Blumberg were awarded the John Scott award for their synthesis and investigations on Naloxone.  The John Scott award is awarded to those most deserving for inventions that contribute to the ”comfort, welfare and happiness of mankind” John Scott was a pharmacist in Edinburgh, Scotland whose interest were in awarding ”ingenious men or women who make useful inventions” Other individuals who were awarded the John Scott Award included Marie Curie, Thomas Edison and the Wright Brothers.

1996: Professor John Strang made a proposal for Take Home Naloxone via report in the British Medical Journal (BMJ). This report stated the case for community Naloxone and went on to say.

Home based supplies of naloxone would save lives.

Non-fatal overdose is an occupational risk of heroin misuse1 and fatal overdose is a common cause of premature death in heroin users.2 3 4 One of the major contributors to a fatal outcome is the inadequacy of heroin users’ responses to the overdoses of their peers. They may delay calling an ambulance for fear of the police arriving, and their efforts to revive comatose users are often ineffective. The distribution of naloxone to opiate users was first mooted in 19925 as an intervention that would be life saving in such situations.6 With a rising toll of deaths from heroin overdose it is time to take the suggestion seriously.

  This study also concluded that at least 80% of those in an overdose situations were witnessed by peers. This posed the question as to why so many fatalities were found alone and on further investigation it revealed that there was even more reason to further investigate and promote the need for community provision of naloxone distribution by peers and significant others .

1996 also saw pilot programs started in 15 American states and the district of Columbia. All results from these pilots were positive. Chicago Recovery Alliance became one of the first providers of Naloxone to peers and the first Take Home Naloxone program went live in the USA. In the following link Dan Bigg talks about this groundbreaking achievment…. http://harmreduction.org/issues/overdose-prevention/tools-best-practices/naloxone-program-case-studies/chicago-recovery-alliance/

1998: Other areas that followed suit with initiating THN programs were Bologna, Padua and Turin in Italy and Jersey in the UK pioneering peer led take home Naloxone programs.

1999: Australian studies found that Naloxone provision was ”not only feasible but acceptable in the community with regards to the target population” The report eventually materialised in December of 2011 in the form of the ACT program…. http://www.atoda.org.au/policy/naloxone/

2000: The ACMD (Advisory Council of Misuse of Drugs) released a report entitled ”Reducing drug related deaths” This document recommended further exploration of the efficacy of Take Home Naloxone programs. This report stated that ”Attempts are needed actively to involve drug users themselves in responsibility for reducing drug-related deaths” The full report can be read here… http://www.drugsandalcohol.ie/5017/1/Home_Office_Reducing_drug_related_deaths_2000.pdf

This year also saw the release of a report from Australia stating that based on the earlier studies in 1999 the ‘feasibility’ of the THN program had met with substantial legal challenges.

2001: San Fransisco and New Mexico began ‘distributing naloxone hydrochloride to heroin users as a simple, inexpensive measure with the potential to reduce mortality from heroin overdose’ There were again legal aspects that caused restrictive supply due to the ‘uncertainty about its legality or the risk of malpractice suits’ Naloxone was seen as a politically charged topic. This fear and uncertainty slowed the process of further provision in other states and around the world. Despite the evidence already being insurmountable as to it’s effectiveness as a life saving medication…. http://www.fixpunkt-berlin.de/fileadmin/user_upload/PDF/Notfall/Artikel_burris_naloxone.pdf.

This year also saw the the beginning of a Take Home Naloxone program in the UK in South London. The original Chicago program became the trusted format for Take Home Naloxone programs globally.

2002: This year saw the first ever reports of lives saved through the community provision of Naloxone and was reported in the BMJ (British Medical Journal) by Chicago Recovery Alliance. This report stated that there had been 52 successful reversals to date since the inception of their take home Naloxone program…. http://www.bmj.com/rapid-response/2011/10/28/chicago-experience-take-away-naloxone

2003: A report was released which has been cited in numerous other publications stating that the high risk period following release from prison, more prominently among females needed to be addressed and looked at with regards to naloxone being provided to those leaving the prison population. The first two weeks following release from this environment are particularly high risk with regards to overdose being prevalent for obvious reasons, tolerance, etc. Further studies took the research into the 12 week period where the findings can be found here…. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2955973/#b22

Also in 2003 there was a further report aimed at the community use of naloxone. This report was aimed at highlighting the reports of risk of overdose following administration of naloxone. The results of this study, which included 998 case studies, showed that after a period of 12 hours following naloxone being given in the field, and further support being refused there were no listed fatalities. This challenged the commonly used reasoning against community provision of the risk of overdose after naloxone wears off, 20 minutes later. 12 hours allowed for this short acting period, and also for the fact that after being administered naloxone the withdrawals would require redosing of opioid for relief. This report was reviewed by dates, times, age, sex, location, and ethnicity when available.

2005: The first report on THN programs was released in USA showing that there was unsurmountable evidence to support the program. The pilot study was carried out in 2001 and released here in 2005. http://www.ncbi.nlm.nih.gov/pubmed/15872192

This year also saw the UK law changed to permit the the use of naloxone by any member of the general public for the purpose of saving a life. http://www.naloxone.org.uk/index.php/lawpolicy/law/uklaw1

2007: The 2007 UK Clinical Guidelines supported the use of naloxone as a means of preventing fatal overdoses and reducing drug related fatalities.

This year also saw the NTA (National Treatment Agency) initiate training for families, carers and users following a survey that identified the need for take home programs to reduce the fatalities.

2008: Both the USA and the UK released an impact paper showing the effectiveness of training in overdose awareness and Naoxone administration to families, carers and users. This showed the potential positive impact that Naloxone in the community could and indeed was having.  http://www.biomedcentral.com/content/pdf/1477-7517-4-3.pdf?origin=publication_detail The release of this report highlighted a number of potential barriers including. Political climate and prescription laws.

The MRC (Medical Research Council) approved the N-Alive program. This was a randomised controlled trial aimed at research within the prison community. http://www.kcl.ac.uk/ioppn/depts/addictions/research/drugs/N-ALIVE.aspx fronted up by Professor John Strang, (This is still ongoing, The randomised trial period ended in December 2014 and the follow up of those involved in the trial will commence in March, 2015) Results from a similar study can be found back in 2003, follow the link to NCBI (National Centre for Biotechnology Information)

2009: In 2009 the NTA (National Treatment Agency) funded 16 pilot trials all over England. These pilots set out to train the carers and significant others in all matters relating to Naloxone. Information on the product, basic life support and overdose awareness, including administration. Overall the project was found to promote the reduction of fatalities induced by opioid related overdose. There was difficulty and resistance reported in finding individuals to train but 495 carers were trained and evidence relating to the training showed that, in reality, the training would be better served in a peer to peer environment.

This was also the year that Wales launched it’s first pilot program as well…. http://wales.gov.uk/statistics-and-research/evaluation-take-home-naloxone-demonstration-project/?lang=en The full data and evaluation report around the 34 areas where this spanned out to can be found here in a report stored on the Welsh Harm Reduction database…. http://www.wales.nhs.uk/sites3/documents/457/Naloxone%20report%202013%20FINAL.pdf 2130 kits were issued between 2009 and 2013 the full statistical data has been reproduced in the report.  

2010: Scotland launched the National Naloxone program. This progress started in 1996 when the BMJ (British Medical Journal) proposal by Prof John Strang was released, see earlier comments from 1996. This move followed a number of pilot schemes and the end result was that pre-filled syringes of naloxone are now provided to everyone considered at risk of overdose, this is after comprehensive training is given. The lord advocate endorsed the program and the National program is fully funded by the Scottish government. The Lord Advocate guidelines can be found here…. http://sdf.org.uk/sdf/files/LordAdvocatesGuidelines.pdf There are numerous reports from Scotland around the provision of Naloxone and the success of the National program. NHS Highlands also now provide nasal naloxone as well as the prefilled syringe.

2011: The Assembly Government in Wales announced their plans to make take-home naloxone available alongside training. This decision followed the evaluation report that was submitted which is here…. http://wales.gov.uk/statistics-and-research/evaluation-take-home-naloxone-demonstration-project/?lang=en

2012: The CDC (Centre for Disease Control and Prevention) and the FDA (Food and Drug Administration) hosted a workshop that hosted a large number of presentations including topics such as populations at risk, public health interventions, criminal overview, ethical and regulatory considerations, expanded considerations, and lots more. The full details and presentations an be found here…. http://www.fda.gov/Drugs/NewsEvents/ucm277119.htm

The UNDOC resolution 55/7 clearly recognised that the high number of opioid related deaths demanded immediate assessment and action, this statement was based on the world drug report 2011, https://www.unodc.org/unodc/en/data-and-analysis/WDR-2011.html This report clearly stated that opioid overdose treatment, ”including the provision of opioid receptor antagonists such as naloxone, is part of a comprehensive approach to services for drug users and can reverse the effects of opioids and prevent mortality” This report also recognised that there were a number of public health inequalities that also contributed to addictions and overdose including, polyuse, mental health, etc. The full resolution can be read here…. https://www.unodc.org/documents/commissions/CND/Drug_Resolutions/2010-2019/2012/CND_Res-55-7.pdf

The N-ALive (NAloxone InVEstigation) trial went live. A full understanding of the content of this investigation and the different stages which include the pilot trial and then the full trial, the reasons the trial was randomised and how the final results will be used can be found here…. http://www.kcl.ac.uk/ioppn/depts/addictions/research/drugs/N-ALIVE.aspx As stated earlier the randomised period of this investigation finished in December 2014 and the follow up to this will commence in March 2015.

The ACMD also released a report recommending that the department of health make naloxone more widely available and also that the prescription only status be reviewed. The full report from the ACMD ”Consideration of Naloxone” went as follows…. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/119120/consideration-of-naloxone.pdf

Over in the USA in 2012 the AMA (American Medical Association) adopted a policy to endorse THN, The endorsement read….

Promoting Prevention of Fatal Opioid Overdose

Opioid addiction and prescription drug abuse places a great burden on patients and society, and the number of fatal poisonings involving opioid analgesics more than tripled between 1999 and 2006. Naloxone is a drug that can be used to reverse the effects of opioid overdose. The AMA today adopted policy to support further implementation of community-based programs that offer naloxone and other opioid overdose prevention services. The policy also encourages education of health care workers and opioid users about the use of naloxone in preventing opioid overdose fatalities. “Fatalities caused by opioid overdose can devastate families and communities, and we must do more to prevent these deaths,” said Dr. Harris. “Educating both physicians and patients about the availability of naloxone and supporting the accessibility of this lifesaving drug will help to prevent unnecessary deaths”

Full list of other indorsements can be found here for general interest…. http://www.ama-assn.org/ama/pub/news/news/2012-06-19-ama-adopts-new-policies.page

2013: The AMA (Australian Medical Association) closely followed the lead of it’s American counterparts and also endorsed THN programs. http://www.anex.org.au/ama-and-its-naloxone-policy-position/

Coffin et al released a paper showing the cost effectiveness of naloxone programs…. http://www.ncbi.nlm.nih.gov/pubmed/23277895 this report was cited in a further report on naloxoneinfo.org…. http://naloxoneinfo.org/sites/default/files/Cost%20Effectiveness%20Summary_EN.pdf

A further report in 2013 looking at yet another myth that states that naloxone promotes increased opioid use as released…. http://www.biomedcentral.com/1471-2458/14/297

Also in this year Victoria department of health fully funded naloxone programs to coincide with already existing overdose prevention programs…. http://hrvic.org.au/naloxone-position-statement/

Martindale Pharmaceutical company releases the only licenced product for community use in the UK…. http://www.prnewswire.co.uk/news-releases/martindale-pharma-launches-prenoxad-injection-for-the-emergency-treatment-of-opioid-overdose-205920351.html

2014: The department of health chairperson Jane Ellison sent a letter the ACMD giving clear direction as to a date for commencement of National Naloxone program from October 2015…. https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/340711/IversonNaloxone.pdf This letter laid out a clear and direct plan of action which advocated for training and any other preparations to be supported prior to the date given for roll out and was adirect relut of the MHRA survey which returned an overwhelming show of support for the provision of Naloxone in the community.

N.A.G. (National Action Group) England was founded to address resistance and cut through the red tape with regards to the THN program nationally. The group is made up of representatives from IDHDP, IDPC, NNEF, DRUGSCOPE, PHE, MORPH, SUSSED, SCUFF, HIT, and also a few other independant representatives. To compliment this Action group a forum was also set up on social media which has members from all areas covered by Health and wellbeing boards nationally and information sharing promotes action in all respective areas.

The World Heath Organisation released new guidelines endorsing THN… http://www.who.int/features/2014/naloxone/en/




Firstly to qualify me for being in a position to input on this subject. I have been involved in drug user advocacy and substance use research on many different levels,  including dual diagnoses, which occurs in a high number of those accessing support through services and mutual aid groups. My role in the field is to add a realistic voice to an often idealistic approach in dealing with and supporting those with multiple disorders and reduce the risks and harm to those living with various conditions including pre-treatment, treatment, aftercare, stigma and various other issues that arise during the care of those I come in contact with. I am lucky enough to be employed in the drug and alcohol sector in UK and also dedicate a lot of my personal time to researching and supporting those living with conditions within our communities.  I would like to also take the chance to thank Louise Rugman for her input and research in this topic and for her ongoing support with regards to the support and care of those living with dual diagnoses, homelessness, and a number of other related issues,  despite her living with an ongoing condition herself. An inspiration by all accounts whose input into my response was valued and informative.

Many thanks Opi Ferum our Australian connection for the thought provoking questions.

1: How do you see people who use substances first-hand living with a mental health issue being treated in the current field of alcohol and other substance care? Do you see harm reduction practices being practiced or not?

With a basic understanding of a number of co-morbid conditions, I’d agree that there has to be first and foremost an element of reducing the risks and harms in this line of care. A number of mental health conditions are not curable, and are indeed long term, and therefore the emphasis needs to be on reducing the harm to the individual and their significant others with regards to minimising the symptoms of the condition and various other aspects of the condition. Harm Reduction  focuses on the minimisation of the physical, social and legal harms, primarily, of those who are living with any kind of condition or disorder among other aspects of care. However, when there is an underlying element of substance use running alongside the condition, which realistically there often is. This can cause controversy with regards to the continuing care for an individual if not addressed and implemented correctly, which unfortunately seems to be all too common. I agree that some form of development orientated practice must also be administered into the care but wholeheartedly feel that the basis of any care, and throughcare,  especially when dealing with dual diagnoses needs to be firmly rooted in reducing harm and minimising risk to the individual whose care is priority and this should be carried right through the journey of that individual, and, those surrounding that same individual without prejudice or discrimination for the use of substances restricting ongoing support.

Harm reduction primarily deals with reducing the consequences of high risk behaviour and sets out to improve the positive outcomes of an individual with regards to supporting them to get the best out of their current situation regardless of their condition. An ideal model of care that I would suggest would be, first and foremost establishing a solid rapport with an individual who is currently living with dual diagnoses, this is imperative with regards to the continued care of that individual. There are a number of benefits here with regards to mutual aid being an integral part of the care of an individual with regards to the concept of an ‘expert by experience’, however due to the nature of the condition there is an obvious need for more comprehensive care and attention, there are agencies that operate a buddy system, whereby the peer support can be advocated for throughout the whole journey of the individuals care. This has proven to be quite effective where practiced. Establishing the cost benefit ratio of continued use and the possible effects when engaging in risky behaviour of any type associated with the condition can be a positive aspect of engagement, however this is not always paramount in an individuals mind when having an episode, for instance, but, it does serve as a positive piece of work with regards to raising awareness around pro’s and con’s of continued use and perhaps preparing a proposed care plan to support specific situations once triggers are recognised. Relapse prevention and setting individual goals for change are again an imperative topic for discussion with regards to an individual’s care. Discussing possible coping mechanisms for any given situation and looking at how to deal with crisis as and when it arises. Mutual aid forums and positive social network interaction again is something I advocate for with a passion, right through an individual’s care and beyond.

So, do I see this working effectively in services designed to care for and support individuals with co-existing conditions. Yes, I do see this happening, but not as often as I would like to…sadly there seems to be a lack in partnership working to fully support an individual living with dual diagnoses.  Also another take on this from an individual who has accessed service for dual diagnoses is that there is an element of confusion with regards to the message being delivered on interventions. Her view was that harm reduction was openly advocated for and promoted within the mental health support service, however, most of the therapies demanded abstinence? One specific report that I have been given in a number of feedback scenarios is access to Dialectic Behavioural Therapy. This is now being highlighted as a therapy that could be used in drug and alcohol services but until then is primarily given as a therapy via mental health services and complex needs teams. This however along with a number of other therapies that are specifically aimed at promoting wellbeing within the sector ‘demand’ abstinence, even from prescribed OST, and therefore there are a number of dual diagnoses individuals who will not be able to access a number of therapeutic treatment options. This in turn excludes a number of individuals with dual diagnoses from entering effective therapeutic alliances with supportive structured therapy options until not only have they moved away from their substance use, but, also way from their OST as well, I have met a few who have been put in the unrealistic situation where they are being ‘pressured’ to implement rapid reduction detoxes to continue their care, or face closure until such times as this is achieved.  Therefore by my reckoning, the tools needed to promote well being are not always fully available, and further to that are not accepting of the fact that there are those who may relapse during the therapy, due to stress and a number of other contributing factors. This unfortunate situation has arisen a number of times both in my personal life and also in my professional capacity where there has been an almost non-existing care plan offered from mental health services dealing with dual diagnoses other than a demand for abstinence when referring in for support for substance use, or, completely the opposite, an extremely comprehensive care plan that cannot be put into action until abstinence is achieved, putting undue stress on the individual going through the process.   Now although I understand that there are a number of reasons why abstinence would be suggested, the main one being it is hard to diagnose an individual who is currently taking a substance which could possibly alter the chemicals in the brain to a point that a correct diagnosis may not be reached immediately, which could cause further distress with the individual, also the fact that substance use on top may not be as effective when using illicit substances on top. However, this becomes a catch 22 situation if an individual is self medicating and presenting with dual diagnoses. If there is no structured joint work between substance misuse services and mental health services and this demand for entire abstinence becomes a barrier to dual support for a dual diagnoses, then, this in my opinion leaves a wide opening for lack of persistent and consistent care and promotes a support network that is fraught with holes. Which are all too easy for those seeking care to fall through.

So to summarize yes I do see harm reduction initiatives working well in Mental health services but there is room for improvement and a more responsive and productive alliance with other services and also within service, to reduce the stress for an individual in the system, by promoting clear and direct access to consistent therapies designed to reduce the risk, without unrealistic ‘requirements’ being imposed or exclusion for substance use, especially substitute medications therapy.

2: How do you personally see harm reduction as a sensible approach to dealing with substance use and mental health? After all, a lot of people that use substances are co-morbid in diagnoses.

I see harm reduction as being of maximum importance when dealing with those living with co-morbid issues in this context. Firstly, as I have stated there are a number of dual diagnoses individuals that have conditions that are ongoing and require ongoing assistance and intense support. Mental illness is not something that can be taken lightly and most definitely not something than can be covered with a blanket policy under the abstinence banner. There are a number of diagnoses that until science and research moves forward, which it does on a daily basis, are constant and require consistent reviews at any particular time to reduce the risk and harm to the individual and those surrounding the individual, as mental health and substance use  can also be a strain on family and significant others, which needs to be, and indeed is, focused on harm reduction with a view to supporting all involved to achieve the best out of a current situation or occurrence, or general well being.

With bipolar disorder for instance there are a number of contributing factors that require a solid and comprehensive approach based in the harm reduction ethos. This is a condition that presents itself with a number of reasons that support harm reduction due to the nature of the condition. Although there are major concerns that would advocate for the abstinence route, and this should at all times be the desired goal, it is not always as clear cut as it may appear. Bipolar and substance use go hand in hand, and, this condition is one of the more prominent that I have come in contact with, with regards to dual diagnoses. Yet as I have said before, a lot of the proposed therapies that are designed to support an individual with this particular diagnoses are aimed at those who are abstinent? Therefore, putting a major barrier up for those who are living with similar conditions, rather than, supporting and offering alternative therapy,  to increase chances of any positive steps towards recovery, by definition, from certain aspects of the condition.

The duty of a substance misuse support agency is primarily to deal with the substance side of dual diagnoses and with all the best intentions it is not really common that you come across a practitioner that is equally qualified in both sides of this coin, this being said, as a practitioner in the substance misuse field when I am dealing with those with current and historic dual diagnoses I am constantly advocating for joint, partnership working for the better outcome and not always successful in this due to unrealistic requirements for continued care and support, which is not ideal in supporting an individual through the process.  Although I have no doubt there are a number of highly trained individuals out there who do have a full understanding of both sides (I unfortunately am not one)  Therefore, they would primarily be dealing with the substance and all it’s related issues. However, once a certain level of reduction in substance use is reached there is the risk of relapse due to the mental health condition taking prevalence, especially if the individual has been using a substance to self medicate? This is where I feel the abstinence call from mental health services gets taken out of context and should be re-evaluated with regards to a demand for abstinence, amongst other things. And this is again where a number of those with dual diagnoses end up falling through the net through lack of joint working between services, or unrealistic requirements being set out prior to continuation of care.

Harm reduction in the role from the substance misuse angle provides a solid safety net for those who are going through the mental health service support network and may fall through the net for a number of reasons. That being said harm reduction drug and alcohol services are not an alternative or as I have heard it affectionately called a ‘dumping ground’  for those who structured support within the mental health service is proving to be partially unresponsive. It is a complimentary support service to run alongside the already existing support network yet all too often seems to be seen as a completely separate service prior to mental health service engagement.

Another issue that rears it’s ugly head here in this arena is the fact that there were a number of services set up to deliver specific services based in dual diagnoses, exclusively,  but due to the payments by results scheme, which has been a roaring success?? the services which were aimed specifically at this field were not seen to be a financially secure ‘investment’  in that the outcomes of ‘complete’ recovery as a dual diagnoses outcome is not always achievable in this particular arena. Thus putting pressure on the relevant services to enforce policies and procedures that are not truly reflective of the individual needs. There is clear and professional guidance for mental health services to promote joint or collaborative working relationships for the due care and attention of an individual that presents with dual diagnoses, however, those services are now commissioned based on a recovery model that given the nature of the condition is unrealistic to uphold without ‘enforcing’ specific requirements, one of which unfortunately is the abstinence ‘need’ for therapy in certain cases. Herein lay the dilemma where if an individual is not currently abstinent or not seen as being someone who can achieve abstinence, in a specified timescale, they then become a burden on service that has targets to meet in order to secure it’s funding for the next year. Harsh but sadly the truth. Hence the lack of joint working or restricted joint working until abstinence is achieved. Verging on Nimby-ism?… possibly!

3: How do you feel a mental health diagnoses affects a person that uses substances? Do you feel it puts them in a position whereby their drug use overshadows their mental health, for example? Or the opposite? Or don’t you think it makes any difference?

I think that a mental health diagnoses can be a lot to deal with for an individual, but at the same time can be a relief due to there actually being a basis for otherwise unexplained episodes during the individual’s life. Whatever the outcome following a diagnosis there is without doubt an element of stress, confusion, fear, and a number of other contributing factors that could put an individual at added risk. Its not every day that you are given a diagnosis that could have a major effect not only you but on every other aspect of your life and those involved in your life.

This can have quite an effect on an individual. And in turn on their substance use, if this is a co-occuring trend in that individual. I wouldn’t say that it doesn’t make any difference as it most definitely would. The effect however would depend massively on the individual. Neither ‘should’ overshadow the other as both are issues that overlap in a number of ways and both are relevant in the progress of the other, however, I can see how one could take prevalence over the other at any given time during the individual’s journey. Another reason for comprehensive dual support.

Again relaying from a discussion around this with my partner, who has been through this situation. When given a diagnosis, although there was a sense of relief that went alongside it there was also understandably a sense of overwhelming fear and lack of understanding that came with the diagnosis which resulted in her pulling away from services for a period of time to digest the information, an obvious reaction in a situation of this magnitude, however…..this highlights a concern, in that, this is obviously a testing, scary period and quite a vulnerable situation for an individual, yet with the facts being presented to the relevant services, she was then able to ‘disappear under the radar’ for a number of years without due care and attention being given to support the news given. Surely there is a duty of care here with regards to this? Or am I mistaken in believing that this may be a regular occurrence that repeats itself in similar situations, which, given the serious risky behaviour (a recognised trait) that could follow, could put an individual in the red on the RAG system, (high risk to self or others) and in a precarious situation. Here I have to ask, how is it possible for someone to effectively disappear, and in all honesty, be able to disappear without being subject to some kind of preventative measure being taken to ensure minimal risk to the individual after being given news of this kind? However, once resurfacing the first place she accessed was the substance misuse service for support as it was made  clear on her first access in treatment, where she was diagnosed with her condition, that her substance use would have to be dealt with prior to her mental health issues being effectively addressed?

There are a number of research papers and debates surrounding dual diagnosis that are almost reminiscent of the chicken and egg scenario, however this seems small in comparison to the fact that there is an individual presenting with a need for immediate support regardless of what came first. Surely? This would transpire during care within a systematic approach that involves substance use and mental health services joint working for the better towards an outcome that promotes well being for the individual.

I must also add here that there is a massive responsibility here on the way news of this nature is delivered to an individual and also how it is seen to be supported in follow on care. Both sides of the care spectrum here are of equal value in promoting the best outcomes for an individual when on the outside devising further care plan. however as I have said there will be different responses from every individual who finds themselves in this situation. And each individual response should then be taken into account with regards to next steps with the care of that individual encompassing all avenues of care equally and with dual importance inclusively.

If one is left to put more emphasis on the other then I fear that the evidence would create a never ending circular effect rather than one of positive steps forward towards any positive definition of recovery.

4:  How would you like to see services engage with people that use substances with a co-existing mental health issue…for example…would you like to see more advocacy for mental health issues within the alcohol and other drug community? Are more services needed? If so. can you think of any in particular?

Collaboratively? There seems to be a distinct barrier towards supporting individuals with dual diagnoses and other co-existing conditions. And  trend for ‘either or’ support. Not totally, I might add,  but it does exist and it is quite frustrating to a professional trying to wade through the paperwork and the requirements and the target setting etc, etc, to meet specific requirements set out to ensure continuity of  care. So, that being said, is it any wonder there is a high rate of drop out in dual diagnosis recovery statistics. There is also the existing and very relevant social inequalities issue around differing support and care that also adds a little spice to the state of play. Another issue worthy of debate on another platform, social, economical, environmental, etc….

With regards to advocacy within substance misuse services I feel that there is always room for more advocacy for something of this magnitude which is of high importance and can be severely detrimental to an individual if they are not given an all inclusive support package to coincide with the delivery of a diagnoses. Having said that I am fortunate to be able to say that, in my experience, there has always been a frontline approach within substance misuse services towards mental health issues in ensuring there is full support and wrap around service engagement when dealing with dual diagnoses at every level, within remit. I do think that there could be more peer support and support groups put in place on the mutual aid front to support individuals living with dual diagnoses. And that this is something that is possibly being overlooked in the current abstentionist movement. Because of the high risk of relapse in thoughts feelings and behaviours, as well as substance use, however, this is where harm reduction is all inclusive in it’s outlook to promoting ‘full’ recovery and supporting those for who ‘full’’ recovery may not be possible, in every aspect of their lives. It supports the individual to achieve a full and positive outcome regardless and also to achieve acceptance both personally and within their respective communities regardless, without putting unrealistic targets, requirements and aspirations on them at the same time.

With regards to services, it is unfortunate that there were services out there that were primarily set up to deal with dual diagnoses, but as mentioned previously they are being systematically dispersed due to cuts, and, being in the unfortunate position of not meeting current payments by results criteria. A sad state of affairs where an already stigmatised group of people are now being restricted in care options because of financial and economic distress. The negative impact this could have on an individual seems to have been lost in a quagmire of finance and social cleansing. Perhaps if we were to challenge that brilliant marketing tool for big pharmaceutical companies, the DSM, and bring it back to individual care rather than profit then there would be more realistic and less idealistic approaches and more funding to put into supporting these individuals rather than paying out extortionate fees for excessive over prescribing of medication.

More services are always needed to cover dual diagnoses, in my opinion, however a re-assessment of those already existing services that are involved in the care and attention of those with dual diagnoses would serve purpose for the time being in a climate of ‘more for less’ at the cost of less intense care and support for the individual at the heart of it all . And a more open and inclusive approach to dealing with and supporting those who are living with co-morbid conditions which includes more support groups aimed at peer support and mutual aid and more public understanding of the realities of dual diagnoses.

It would appear that there is a flaw in the current recovery agenda that does not take into consideration those for whom ‘full’ recovery may not be possible, and with current financial cuts hitting the sector hard where it is most effective, and indeed most needed, the safety nets are being dismantled and taken away from the providers that cater for those who are caught in the middle.

My Views on the Trews (End the drug war)

In a recent documentary from Russell Brand which can be found here….http://www.bbc.co.uk/programmes/b04v2zrg….there were a number of issues that came up for me. Now before I rant I will be clear that I have respect for Russell on a number of social issues that he is openly exposing and supporting but this particular one is fraught with uncertainties for mecand if not challenged has the potential to cause more damage than good.

By Russell‘s own admission in his first TV slot to address policy and addiction, he only speaks on behalf of a small portion of PUD’s (People who use drugs) Statistical data would say that only 20% of the user community are, by definition, problematic. 80% use in moderation and recreationally. Therefore he is talking for the minority when looking at needs and
status. and while I fully understand where he is coming from and understand what he is saying, he is indeed speaking on behalf of the minority, again by definition. Therefore if his word was to have an influence on the current policy reform debate, it would only cover the smaller portion of PUD’s, which is the problem we are already faced with. Once again the majority would be left out there with limited support services designed to meet their needs, in fact even less as the very core of the recovery movement, the harm reduction platform on which almost every recovery journey is built on, is being severely dis-invested in and this is indeed having an impact on the final outcomes. Which could result in even less making it through to ‘full’ recovery, health wise, emotionally intact, physically intact and mentally intact,So, although I won’t knock him for his advocacy and his core beliefs, he is indeed very dangerously advocating for what is already there, policy aimed at the minority which in return becomes detrimental to the majority and restricted support for the majority with abstinence at it’s core.

I am a firm believer in the by any means necessary concept when it comes to recovery and advocate for a wide spectrum when it comes to this. I don’t believe that recovery demands abstinence but do believe that the end game of anyone on that journey is and always has been to reduce harm, risk and eventually move out of dependence, possibly towards abstinence. One foot in front of the other, no enforced steps, just positive ones, big or small.

I’m not knocking abstinence in any way shape or form and fully support whatever works I’m also aware that having one chosen route as the key element for basing a whole policy and agenda on doesn’t work either. Never will a blanket policy for any issue ever get the results it sets out to achieve in full. Abstinence has worked for many but so does moderation. Having blanket policies tends to isolate more than it supports in whatever arena they are pushed into. As an individual I promote reduced harms and risks regardless. There is a massive difference between standing in a camp and publicly standing up and saying that it is the only way, When 80% of those you are speaking for prove different. It kind of takes the power out of the argument if you are not speaking for all, in the public high profile arena it does anyway.

Abstinence is the desired outcome for many who use substances and also for many who defend whatever route they have chosen to walk but its not always what an individual chooses and definitely doesn’t work when it’s enforced or pushed for. Current policy is a smokescreen and demands abstinence when in actual fact recovery doesn’t. Recovery is simply putting one foot in front of the other moving forward at your own desired pace. The end result isn’t a race or a deadline. When someone is in hospital recovering from an accident or something similar, they are recovering from the minute they start getting help and no-one demands any specific outcome from them other than to improve with time.

Just out of interest how long and how many attempts at abstinence did it take for you to finally get there. Speaking for myself I took quite a few attempts during which time I still needed care and support, the way things are moving and the abstentionist movement will not allow for that. It has already created a deficit of individuals who are not accessing services due to the unrealistic demands and drive for positive closure fraught with bargaining and directive, guided assessment with key elements and needs for the population involved in treatment and its culture being used rather than offered as solid basis for first steps towards ‘full’ recovery. The expectations are too high and too daunting at first contact these days and this deems them not fit for purpose to many.

Treatment used to be about working with the individual where you found them, but not leaving them there, it was never about bargaining, punishment and carrots. This is where fundamentalist like Mr Brand are possibly subliminally supporting the agenda despite it having a detrimental effect on the majority of those in that specific community. Its dangerous to push for one specific outcome when there are many. I respect his, and anyone elses choice and won’t take the power out of anyones journey or story.. But….at such a high level of interaction there needs to be open mindedness around the fact that addiction has many issues and recovery has many faces,

The main problem with substance use, or more so the way it is portrayed, is that there doesn’t seem to be any understanding of the concept that that not all use is abuse and this is evident in many of the fundamentalist arguments and this also reflects in the policies and procedures of those in power to make such policies. ALL drug use seems to be portrayed as abuse when in actual fact a huge number of PUD’s do not fall into this category. Moderation does not seem to be acceptable when looking at it from an academic perspective. and this is being enforced into a community that a high number of those indulging in recreational use are a part of. This creates a system that is not designed to cater for the moderation group and when accessing services for an MOT the requirements to get scripted or full support package are based solely on abstinence based interactions. So those looking for an MOT would rather take their chances in the community. This has the effect of making the treatment system and the overall statistical data look like it is doing well by stating that drug use is down when in actual fact it might not be, it might just be that the support on offer isn’t what those looking for support are actually looking for. A systematic design that then looks like the policies are working, big pat on the back (for pulling the wool over the public’s eyes and therefore gaining support to roll out more bullshit policies) ,,,,however,,,,It also has the detrimental effect of crime statistics rising, health issues and risk increasing and sadly fatalities rising which has become evident in last years 32% rise. Now this may or may not be connected to the current adoption of the agenda but the fact that treatment has now become almost elite in it’s cherry picking nature, which was highlighted during the debating period prior to the release of the agenda, is being questioned as to its possible connections to the negative outcomes compared to its positive ones, it does beg the question. And one that a huge number of professionals in the field are now asking themselves. So with a this in mind then the abstentionist movement numbers will dwindle as there are too many expectations and demands from the get go. So unless there is a realistic reform approach to this whole thing which looks at the early stages of support and care and not only the end result then, with more focus on the beginning of the journey and acceptance around the fact that this is the individuals journey and not one that can be guided or enforced or bargained with using scripts as carrots and also as a form of punishment for moderate use, another abstinence smokescreen, sold too early in the game for any positive outcomes to be secured, then the message Russell carries is going to be in advocacy for a stagnant and more realistically smaller number than it already is. Because even if abstinence is achieved some do revert but the services that pick them up will be decommissioned in favour of the final outcome.

Abstinence may well be the Nirvana for some but they’ll never get there if we don’t put the investment back into the basics. And secure the foundations on which to start building the steps towards it. The road to recovery is lined with many tempting lay-byes and lots of individuals on that journey will make a pit stop to rest up and maintain their standing, when they do the last thing that they need is someone sending them back to the beginning of their journey to start all over again, installing a feeling of failure because they stopped for a break. Or punishing them for getting that far but not in the way some shady roadmap said it should have been done. You support them and give them encouragement, not daily pick ups all over again, you comfort them and tell them that is is a journey and not a destination and most definitely not a race. (Didn’t the tortoise beat the hare anyway? proving that it was in the quality and not the pace) The last thing you would say is that they have to travel all day and night until they get to where they are heading, that would cause immeasurable damage, not to mention take the power out of the end result because you would be too busy licking your wounds, or self medicating, because no-one tended to them along the way.

There is a saying that resonates saying to take the road less travelled which needs careful navigation, if it was simple then everyone would take the road everyone else took as it is faster and well trodden, which it would appear is what is expected in current arena, speed and turn over rather than care, time and quality, enjoying the scenery along the way. The abstentionist fundamentalists, not all those who are abstinent, seem to be forgetting where they came from and losing took of how long it took them to get there and also what support they needed along the way. And more importantly how many different routes there, This is dangerous practice and makes those who stumble think that it is not worth getting up and trying again because there is only one way and that way didn’t work for them. It’s not inclusive of those who need minimal support but support nonetheless, ,and it’s too exclusive in it’s content, it needs to be more open-minded, more flaccid and more person centred as that element seems to have disappeared.

Shining the light on one specific area pushes all surrounding areas and options into the shadows and is a trick played by politicians, to deflect our attentions from the real issues at hand. Our approach should be to illuminate the shadows completely with transparency and unity. And to do that we must all be singing the same tune, not just one chorus.


  There have been many individuals, organisations, NGO’s, etc,  that have stood up, and indeed still do, for the civil and human rights of people who use drugs (PUD’s) many have made significant and positive change happen, many still fight to reduce the risks and harms to PUD’s under dangerous and destructive policy and procedure. Raising awareness of the stigmatising and discriminatory practices that serve no purpose other than to demonise an already vilified and vulnerable group.

   In some countries illegal importing, exporting, sale, or possession of drugs constitute capital offences that can result in the death penalty. 33 countries and territories that retain death penalty for drug offences, including 13 in which the sentence is mandatory. These countries include, Afghanistan. Bangladesh, Brunei, China, Egypt, India, Indonesia, Iran, Malaysia, Morocco, Pakistan. Saudi Arabia, Thailand. United Arab Emirates, Syria, Vietnam. Even in the USA the United States Supreme Court in Kennedy v. Louisiana struck down capital punishment for crimes that do not result in the death of a victim, but left open the possibility for “offenses against the State” – including crimes such as “drug kingpin activity” including very large quantities or mixtures of heroin, cocaine, ecgonine, phencyclidine (PCP), lysergic acid diethylamide (LSD), marijuana, or methamphetamine.

 In China and southeast Asia, PUD’s are detained compulsorily in government run centres tht declare they are there to enhance “treatment” or “rehabilitation”. There is no element of treatment or rehabilitation in these facilities and PUD’s are held without the due process protections and less rights than those locked in prisons, no access to legal repressentation, no right to appeal, and no judicial oversight of detention. Some are detained for years without ever receiving any form of evidence-based drug dependency treatment,  in isolation cells, forced to work, and abused by those who should be there to provide care and support. Some forms of torture that are used in these centres incude electrical shocks and many in the care of these centres are sexually abused. There is no process to determine drug dependence either cinical or otherwise.

  These centres also lock up the homeless, street children, and those living with mental illnesses. None of those who are held in these centres are given any kind of health care even in it’s most forms. There may be contact with health proffesionals but this is usually in the form of mandatory HIV testing, forced blood donations, scientific research, (mostly involuntarily) and a number of other inhumane practices.

  Investigations into issues such as risk factors for HIV infection among injecting drug users (IDU), HIV prevalence, effectiveness of behavioural HIV/STI prevention interventions, and the efficacy of particular modalities of drug treatment have repeatedly shown that these practices are inhumane and unethical and yet these practices still continue. The practices are often described, by those who run the facilities as, training centres focusing on “physical exercise, education, information, and job training for PUD’s in the city” What is actually meant by this is that those in these centres are forced to work for at least 8 hours a day as labour therapy, they are forced to attend educational classes but denied any access to standard or recognised educational equipment, the educational content aimed at promoting the needs of the area they live in and not based on educational values or the needs of those being educated. Very basically, PUD’s and other vulnerable individuals who are held in these centres are treated worse than animals and isolated from the outside world. Completely with no civil of human rights and this treatment is indefinite spanning out years in most cases with a high number of those incarcerated dying under the conditions they are forced to live in. The surrounding communities support these ethics because it is easier to use detainees than it is to use someone who lives a ‘normal’ life when looking for employees or similar needs and it is also a lot cheaper therefore research and investigations into the running of these facilities is hard to achieve and access to the majority of them is impossible.

This and a number of other reasons make drug policy reform campaigning a matter of civil disobedience in areas where this kind of treatment is normal practice, and even in some more advanced countries. Campaigning for better programs and more humane practice in most areas is seen as controversial and can at times be dangerous to those who openly advocate for positive reform. This civil disobedience is also related to facilities such as drug consumption rooms, promotion of life saving medications, decriminalisation, equal rights for PUD’s and handing out clean equipment. Most of these actions have been carried out by passionate and dedicated individuals whose principles came before the risks they took when advocating or initiating programs that provided safer practices and safer environments for PUD”s.

It’s ironic really that in order to reduce the risks and harms of those who use substances you must put yourself at risk of harm in some cases, but for the greater good. It’s also ironic that despite this being seen as a form of civil disobedience, it is also based on insurmountable evidence that suggests, in fact proves,  that the practice advocated for is the most effective, positive and productive way to address the issues in most communities and yet many communities stance is quite the opposite in content.

There is however a paradox that presents itself when looking at policy reform. From a political angle those in power must find a solution that reduces the harms to the majority of their constituents. And this can mean economical, financial, emotional, mental, physical, etc. Now by social design that has been manufactured for years, vulnerable groups within communities have been portrayed as being less productive and at times damaging to communities with regards to crime statistics, cost on health services and such, unemployment statistics, homelessness, etc. So when looking at policy reform in any arena there is a conflict of interests when making the decisions that would be of maximum benefit. and when looking at who would be more satisfied with the outcomes of such policies there is more reason to look at the outcomes in potential for votes rather than ethical, public health outcomes.

The need to look at policy objectively, looking at socio-cultural needs, societal influence, public health issues, cost effeectiveness, etc is long overdue but is also a problem that needs to be addressed in stages with both sides of the argument being critically assessed and dissected and this might also mean that there will be recognition on both sides that some draconian policies and procedures have caused more damage than good and this might be where the delay originates from with regards to looking at the overall cost of some of these policies. Based on the evidence presented at the beginning of this article there have been a number of human rights ignored with regards to policy and agenda that have resulted in the deaths of high numbers of PUD’s and members of other vulnerable groups within communities and this would have to be held accountable if realistically taking effective and evidence based policy into account.

There lies the paradox of those who are in a position to make the changes, but even the most ignorant of those in power must know that change must occur, and to delay it any longer simply gives more space to add to the long list of fatalities and other heinous crimes that, in content, by far excede and outnumber any other casualties of war and war crimes in the course of history. The war on drugs, a war on people, needs to end and it needs to end now.



It has been shown throughout history that if 3.5% of the general public stand up against social injustice and move for positive change then it will indeed happen….the last hundred years provide the evidence, sadly this is not the age for evidence based policy and therefore we need to stand taller and shout louder, but change will indeed come”

The role of user activism is clear and precise in it’s aim and objectives. Primarily the role is to raise awareness of the everyday issues experienced by those who are living on the frontline and experiencing the real effects of policies and procedures that affect them. Providing evidence base to counteract idealogical policies that neither support nor reflect the true needs of the user community.

Activists, both individually and in groups, have successfully initiated change in a number of area’s where it was sorely needed and the effects have been instrumental in supporting whole communities within communities to live positive and productive lives in the face of adversity, ignorance and discrimination. Exposing elements of fear of that which is not understood, misrepresentation, misunderstanding, scapegoating, etc, in media, politics and the medical industry to mention few.

As long term global economic trends sway towards a reduction in profit rates and the competition soars to an all time high, the pressures these put on governments, corporations and organisations, have produced a period in which fundamental issues of political and economic structure are at stake an the response is a divide-and-rule political arena to promote stability. This in turn promotes the negative outlook on specific groups of individuals by the term affectionately known as ‘the politics of scapegoating’ People who use substances are extremely vulnerable to this particular form of political escapism. This can, and does, divide communities in ways that weaken opposition to socioeconomic changes and policies and strengthens punitive and individualist ideologies. This then has the negative effect of allowing policies that maintain or increase drug-related harm to continue seeming less an ‘error’ than perhaps a rational way to defend the interests of the powerful.

This therefore, in my opinion, shows that there is indeed a desperate need to develop a political understanding between the policy makers and activist to expand the concept of ‘politics’ and take it beyond specific interest-group politics. Consideration of when and how it might be best to work with groups of individuals for social change from the bottom up, rather than the opposite way round. This political trickery is not only evident in the user community as the current display of negligence with regards to people’s hopes, fears, housing, employment, economic and financial security, becomes common practice in all aspects of the political arena. This may seem like a negative outlook, however, it also can provide the opportunity for collective action against the social-structural sources of the problems.

The term harm reduction has, of late, almost become a taboo subject that despite being firmly grounded in evidence based policy and procedure. In the current climate the harm reduction community is facing disinvestment and the health and safety of people who use substances, which should be of paramount importance, is not being seen as the priority that it should. This is having a detrimental effect on huge numbers of individuals within our communities. The harm reduction ethos is simple…

* To reduce the harms and risks to whole communities by raising the awareness of public health issues faced by people who use substances, looking at productive and positive cost effective solutions to the harms and risks to whole communities.

* To provide a platform for mutual aid support based on effective programs and past experience that has proven to promote the health and safety of all involved. A place where identity and a like-minded train of thought promotes unity and progress in the interests of all involved.

* To support others with similar issues or a vested interest in the care and support of those within the community by consulting and advocating at all levels on a global scale to increase the understanding of the risks and harms that may come with substance use on both individuals and whole communities.

The term harm reduction is ever evolving as the numbers of those involved grow bringing a different perspective and understanding to the platform. As trends and substance use changes, so does the concept and reach of its community members, but it’s core value is to always promote the health and safety of every member of the community by focusing on the individual’s wellbeing based on the above three main objectives.

User activism can take on many forms and ‘activism’ can be something as simple as writing a letter. Anything that ‘consists of efforts to promote, impede, or direct social, political, economic, or environmental change, or stasis‘ can be collated under the umbrella of activism.

The role of user activism in Naloxone provision is to raise awareness around the issues that are current in our communities with regards to drug related deaths etc. With the recent 32% rise in drug related deaths there is a dire need to provide evidence to support any kind of program that promotes reduction. It is clear that current agenda and policy does not effectively reduce the harms or risks that people who use substances face on a daily basis and based on my earlier comment around disinvestment this looks set to get even worse unless something is done about it and a return to evidence based policy and procedure can be reinstated and funded properly to secure the health and safety of the community it represents. As the evidence adds up to show that naloxone works, and the resistance loses its footing, the pressure must be applied to keep the momentum going. Activists all over the world are coming together and providing the evidence needed to support this program. With the current statistical data in UK showing that, on average, 3 individuals die every day of opioid overdose, the need for this program speaks for itself. Those living with the loss isn’t just restricted to the user community, this effects every single member of the community, emotionally, physically, mentally, financially, etc.

This can be approached by a number of ways with regards to activism and actively promoting naloxone in the community. There are a number of websites and groups that have all the information needed around naloxone, the product, the uses, the evidence, the statistics and the law to start a campaign or indeed to join an already existing one. There are also a number of groups and organisations that offer free training. Which once it has been given can be cascaded wherever needed. Lobbying local politicians, and other similar members of the community is another angle that can be taken. Petitions either hand collected or electronically collated can be used to approach health and wellbeing boards, clinical commissioning groups, service providers and other similar groups or organisations. Mutual aid groups and collectives can be set up and have proven to be successful in the form of action groups and harm reduction cafe’s where the main topic has been, but not exclusively, drug related deaths and solutions to reduce the effects this has on communities.

Making yourself available for any consultation in any arena that evolves around the topic and joining the dots in your community. As members of an already vilified and demonised community it is in the interests of everyone who has ever suffered at the hands of ideology, ignorance, discrimination and all it’s trimmings to join together and make sure that as a voice we are heard.

The substances that can induce overdose are not restricted to illicit use, in fact, the majority opioid substances that can be evident in overdose situations are prescribed medications. However due to the barriers that have risen through discrimination and socio-political design it is the illicit use that gets highlighted as the main concern and due to the afore mentioned reasons and negative media coverage the design effect is resulting in disinvestment with fatal outcomes as those who use drugs become the scapegoats of a society that has become part of the problem rather than part of the solution for many.



There was a recent research paper released in DDN Magazine that focused on non fatal overdoses which was carried out by a group of academics in the University of South Wales. Which can be found here….


 Following on from this I decided to do a little non-academic research for myself to look primarily at the possible effects of a non fatal overdose on the individual, Firstly from a physical / medical perspective. In the UNODC discussion paper released in 2013, “Opioid overdose: preventing and reducing opioid overdose mortality” (http://www.unodc.org/docs/treatment/overdose.pdf) it states that….

“Non-fatal overdose can significantly contribute to morbidity, including cerebral hypoxia, pulmonary oedema, pneumonia and cardiac arrhythmia, that may result in prolonged hospitalizations and brain damage”
 Asphyxia and hypoxia lead to a redistribution of cerebral blood flow. This can result in a 25% reduction in oxygen saturation (in lambs, no human research found). Research has found that naloxone can quite significantly reverse this redistribution, this has a massive effect on the oxygen in the brain and therefore, as an opioid-mediated homeostatic mechanism, in hypoxia promotes preferential perfusion of the vital structures of the brain. During severe prolonged asphyxia there was an increase of cerebral blood flow which was more prominent in new born lambs with hypoxia. As opioids play a role in the regulation of cerebral circulation the potential in a non fatal overdose for cerebral redistribution stemmed by naloxone was proven to be significant in redistributing and therefore reducing the the hypertension, increasing the oxygen levels in the brain, reducing arterial blood pressure and reducing the risk of any longer lasting effects. Full recovery and reversal possible if naloxone is administered as soon as is possible after signs appear. For a clear understanding of the signs, symptoms of hypoxia please follow the hyper link below….
 Pulmonary Oedema is fluid accumulation in the air spaces and the lungs which leads to respiratory failure. There are a number of reports published around possible adverse effects of naloxone and most of these include pulmonary oedema, however, most were also highlighted in the presence of an underlying cardiorespiratory disease which has made it impossible to differentiate between what the underlying cause of the pulmonary oedema. “Many episodes of pulmonary oedema secondary to opioid toxicity have been published since it was first noted by William Osler in the 1880s and it has been suggested that naloxone simply reveals the opioid induced pulmonary oedema that had been masked by the already existing respiratory depression”
  Seizures and arrhythmias have also been recorded in pulmonary oedema but ths is more likely to be caused by hypoxia. Which in previous paragraph is reversed by naloxone. Further research around this has shown that hyperventilating patients prior to administration of naloxone could reduce the risk of sympathetic mediated adverse effects. All studies based on this and the findings from those studies were conducted in early trial periods where the main reason for research was to find out what dose of naloxone would be most effective in treatment of non fatal overdose situations to prevent them from becoming fatal. Out of 185 papers on the subject matter, studies were  only deemed to be relevant if they compared doses and routes of administration of naloxone or if they produced evidence about rates and timing of complications. This comment is a summarised account of those that were accepted. For signs and symptoms of pulmonary oedema please follow the hyper link below….
  Pneumonia Opioid analgesia impairs gastrointestinal motility. Enteral administration of naloxone allows selective blocking of intestinal opioid receptors caused by extensive presystemic metabolism. Therefore, the effect of enteral naloxone on the amount of gastric tube reflux, the frequency of pneumonia, Results on studies around this particular subject provided evidence that the administration of enteral opioid antagonists in ventilated patients with opioid analgesia might be a simple—and possibly preventive—treatment of increased gastric tube reflux and reduces frequency of pneumonia. This study was carried out on 84 fentanyl treated human patients and was a prospective, randomised, double blind study with 43% given a placebo. For more information on pneumonia please follow hyper link below…..
 Cardiac arrhythmia: Administration of naloxone before a coronary artery occlusion (http://www.netdoctor.co.uk/ate/heartandblood/203287.html) reduced the incidence and severity of cardiac arrhythmias during coronary occlusion for a period of 20 minutes and reperfusion for a period of 2 hours. It also reduced the mortality. Naloxone totally wiped out the appearance of the life threatening ventricular fibrillation (http://www.patient.co.uk/doctor/ventricular-fibrillation) and ventricular tachycardia (http://www.patient.co.uk/doctor/ventricular-tachycardias) This study again was carried out on dogs, and there is no searchable research on humans. The results suggest a possible involvement of endogenous opioid peptides in arrhythmogenesis (http://medical-dictionary.thefreedictionary.com/arrhythmogenic) during coronary occlusion and reperfusion in the dog.
 Therefore the conclusion of my research is that…again…naloxone is effective in reducing the risks associated with non fatal overdose as well as reducing the risks of the overdose situation becoming fatal. Not bad for a non academic, done in the space of three hours and didn’t cost a penny.