Nobody Wants to Be Narcan'd: A Pilot Qualitative Analysis of Drug Users' Perspectives on Naloxone

Jeffrey T. Lai, MD; Charlotte E. Goldfine, MD; Brittany P. Chapman, BSc; Melissa M. Taylor, BA; Rochelle K. Rosen, PhD; Stephanie P. Carreiro, MD; Kavita M. Babu, MD

Disclosures

Western J Emerg Med. 2021;22(2):339-345. 

In This Article

Results

A total of 28 individuals were screened for recruitment during the study period. Of those, 12 were unable to be enrolled as they either eloped (n = 4), were unable to provide consent (n = 1), had no non-medical opioid use in the prior six months (n = 6), or reason was not documented (n = 1). Of the 16 potential participants who were approached, six declined to participate in the study: three identified as female and three as male, and ages ranged from 28–35 years with a median age of 32 years. Ten participants were enrolled in this study; the demographics of the study participants are detailed in Table 1. The sample was predominantly young, White males who had been in treatment for OUD on at least one occasion. The majority had previously received naloxone. The sample varied on education, employment, and housing status.

Analysis of semi-structured interviews revealed several themes, which are described in detail below. Additional illustrative quotations are included for each theme (Table 2).

Familiarity With Narcan (Mechanism and use)

All participants were familiar with the brand name "Narcan," but some were not familiar with the generic term "naloxone." One individual mistook naloxone for naltrexone. A single participant had never heard the term "naloxone" before. All participants reported having formal naloxone training from sites including local treatment facilities and harm-reduction organizations. Most reported first hearing about naloxone through treatment programs (eg, detox, Alcoholics Anonymous meetings) or correctional facilities, from other people who use opioids for non-medical purposes, and from occasions where they had received it for overdose reversal. Two participants informed study staff that they could not recall how they first learned about naloxone because they had "known about it for so long."

Most participants understood the general purpose of naloxone to be reversing an opioid overdose, yet there were varying degrees of knowledge about the exact underlying mechanisms. The majority of participants used specific terminology implying blockade or antagonism when describing how naloxone works (eg, "receptor," "blocker," and "reversant"). Most participants identified naloxone's specificity for opioids, but there were two participants who also questioned its utility for other substances, such as alcohol.

All but one participant reported that they currently or previously possessed a naloxone kit. Of those nine, three participants reported that their reasoning for carrying a kit was to save the lives of others. One participant stated, "If someone needed it, I would rather have it than be powerless." The majority of participants reported obtaining naloxone kits that contained the newer, "easy" plunger-style nasal spray. Three participants mentioned that they had previously obtained the more "difficult to use" older version that required assembly.

Naloxone is Available and Easy to Obtain

Participants universally agreed that naloxone kits were available and easy to obtain from a variety of organizations (eg, pharmacies, treatment facilities). All participants knew the process for obtaining a naloxone kit, and several reported obtaining it from a harm-reduction agency (eg, needle exchange) that distributed it for free and provided training. When asked how programs that distribute naloxone could improve their services, some participants suggested increasing access by providing naloxone kits by default whenever someone visits a needle exchange or leaves a treatment program, and by implementing mobile programs of outreach workers to distribute it within the community.

Naloxone Availability is Viewed Positively

Participants perceived naloxone as a life-saving drug and were thankful for its presence in the community. One participant stated, "[I] think it's an amazing drug. I've seen it save people's lives." Some participants reported feeling empowered by carrying naloxone and said they would use it to revive someone. When asked how individuals who had been revived by naloxone were perceived by other people who use opioids, many participants responded by saying they were "lucky." Some participants stated that they themselves felt lucky after being revived with naloxone.

Naloxone Produces Aversive Symptoms During Reversal

All participants who had previously been revived with naloxone reported experiencing extraordinarily unpleasant physical responses consistent with severe opioid withdrawal (eg, nausea, vomiting, diffuse body pain). One participant described it as the worst pain he had ever experienced. When these participants were asked about their emotional response, several disclosed that they felt embarrassed or experienced feelings of depression and anxiety regarding their return to opioid use. Participants acknowledged that receiving naloxone was an experience that they would go to great lengths to avoid. However, in the event that they were to overdose and require naloxone to save their life, they hoped someone would administer it.

Availability of Naloxone Does not Increase Risky Drug-use Behavior

Participants were unanimous that their decision to use opioids did not depend on naloxone availability. While participants speculated vaguely that a hypothetical "other" group of people who use opioids might adopt riskier drug use behavior due to the availability of naloxone (such as taking bigger doses or using more often), all participants explicitly denied that they themselves engaged in riskier behavior and/or increased their opioid use in any way due to the availability of naloxone. Several participants reported that they had recently experienced a return-to-use event, but none identified naloxone availability as playing any role in this occurrence.

Several participants stated that they had heard of or had seen others using heroin/fentanyl immediately after being revived with naloxone to mitigate withdrawal symptoms. One participant reported doing this herself, while simultaneously noting that this was "messed up." Participants reported that people are using in groups as a harm reduction strategy and likened using alone to a death sentence.

Barriers to Carrying Naloxone are Primarily Related to Potential Social and Legal Consequences

Participants described several potential barriers when speculating why an individual might choose not to administer naloxone: fear of legal repercussions; not having naloxone available at that moment; and not wanting to interrupt the individual's euphoric experience ("high"). Interestingly, some participants felt that having naloxone on their person would be perceived by other people as an admission that their recovery might not be successful, and that this decreased their desire to carry it. Of note, two participants expressed concern that carrying naloxone might be interpreted specifically by authority figures (eg, parole officers) as a return to drug use, which would potentially result in legal repercussions. None of the participants had ever self-administered naloxone or knew of anyone who had; all believed that it was impossible or very difficult to do so when indicated.

Good Samaritan laws, which vary by state, protect individuals from prosecution for drug possession if they seek emergency services assistance for a suspected overdose.[11] Nine participants expressed some understanding of the Good Samaritan Law in Massachusetts, but there was variable comprehension about what this law covers. Several participants also expressed concern over whether law enforcement agencies would adhere to these laws.

Additional Novel Findings

Most participants shared the belief that the majority/all of the current "heroin" supply in their community is actually fentanyl, and that obtaining "real heroin" was a difficult thing to do. Fentanyl was reportedly less desirable because it was perceived as more dangerous and shorter-acting than heroin, requiring more frequent dosing. Most participants identified cyanosis as the major indicator differentiating the desired opioid effect from an overdose. These participants described the presence of a skin "color change" to blue as the signal to administer naloxone.

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