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The Scottish Drug Forum has warned pharmacists that multiple doses of naloxone may be needed to reverse drug overdoses, following the discovery of synthetic opioids in various street drugs in Scotland.
In an ‘Overdose alert‘ issued on 13 March 2025, the Scottish Drug Forum warned that drug-related harm, including near-fatal overdoses, has increased throughout the country, with nitazenes being been found in several street drugs, including heroin.
Forwarding the alert to pharmacists, Community Pharmacy Scotland (CPS) published advice on 14 March 2025, which revealed there has also been a recent increase in reported sudden collapses after injecting or smoking heroin.
“The concern relates to clusters of drug-related harm, including both near-fatal overdoses and deaths,” CPS said.
“As a result, Scottish Drugs Forum has launched refreshed information to raise awareness of the signs of overdose and how we can reduce risk.”
In its advice, CPS advised pharmacies to ensure staff are familiar with the signs of overdose and of the increased incidence of drug-related harm; make sure staff are aware of the community pharmacy emergency supply of naloxone service; and check that naloxone stock is in place and in-date.
The Scottish government added a naloxone emergency supply service to the community pharmacy public health service in October 2023, with funding for “two kits”.
A spokesperson for the Scottish Drugs Forum told The Pharmaceutical Journal: “The advice is to administer naloxone as per training, as per usual advice. Anecdotally, there is evidence that some people have had more than one dose administered but this is not unusual. Each naloxone kit contains one nasal [spray] or syringe for administration that contains several doses.”
Commenting on the overdose alert, Catriona Matheson, former chair of the Scottish Drugs Death Taskforce, said: “We are concerned that heroin is contaminated with a nitazene-like substance, causing a number of overdoses. Given the potency of nitazenes compared to other opioids, higher or repeat doses of naloxone are required.
“Pharmacy staff should be aware of this and share with those at risk that there is a contaminated, toxic supply of heroin circulating. Messaging should not refer to a strong supply, as that can appeal to some people. Pharmacy staff should reinforce the need to carry more than one naloxone kit, as the experiences has been that repeated doses are being needed when an overdose occurs.”
Amira Guirguis, chair of the Royal Pharmaceutical Society’s science and research committee, said: “Recent reports of sudden collapse following heroin injection or smoking are highly concerning and suggest a shift in the composition of the illicit drug supply. This may be due to the increasing presence of potent synthetic opioids, such as fentanyl and nitazenes, used to fortify heroin, often combined with other central nervous system depressants like alcohol. The rapid onset of overdose symptoms and the need for multiple repeat doses of naloxone to reverse respiratory depression reflect the potency and complexity of these drug mixtures.
“The increasing presence of xylazine — a non-opioid sedative — in adulterated heroin adds further complexity. Xylazine-induced respiratory depression and bradycardia are not responsive to naloxone, but naloxone should still be administered in suspected opioid-related overdoses to address any opioid effects.
“This evolving overdose pattern highlights the need for greater awareness among healthcare professionals and first responders. Widening access to naloxone distribution is essential to improving outcomes and reducing premature deaths.”
Neil Gray, the Scottish health secretary, added: “Ongoing surveillance has highlighted the possible contamination of heroin in Glasgow, Dumfries and Galloway, Ayrshire and Arran and Lothian. We will continue to monitor the situation and work with partners including Public Health Scotland, the Scottish Ambulance Service and Police Scotland.
“We’re working hard to respond to the growing threat from xylazine and highly dangerous synthetic opioids like nitazenes, in an increasingly toxic and unpredictable drug supply. Such synthetics increase the risk of overdose, hospitalisation and death and are being found in a range of substances.
“We have provided more than £300,000 to ensure that all community pharmacies hold naloxone and are able to administer it in event of an overdose. All community pharmacies should hold at least two naloxone kits.”
