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

Discussion

Our participants were familiar with and accepting of naloxone. They were also willing to administer this medication to someone who had overdosed. However, participants tended to rely upon the presence of cyanosis, a late finding in overdose, as the indication for naloxone administration. Despite a willingness to carry and use naloxone, we found that some participants associated possession of naloxone with feelings of weakness or potential failure. We found that participants denied engaging in riskier opioid use behaviors when naloxone was available. In fact, some individuals who had previously overdosed and received naloxone held such a strong aversion to the experience of precipitated opioid withdrawal that they reported subsequently using less drug to decrease their overdose risk. Although our data set was small, we did establish thematic saturation for a preliminary study with respect to the question of whether naloxone facilitated riskier drug use: Our participants were unanimous in reporting that they did not decide to use opioids nor increase their opioid use because of increased naloxone availability.

Previous studies have indicated that non-opioid users hold overall positive opinions of naloxone.[12–14] A survey of lay persons found that while only 61% of respondents had heard of naloxone, most respondents (88%) felt naloxone was beneficial in preventing accidental opioid overdoses.[12] Both medical professionals and state government agencies support efforts to increase naloxone availability due to demonstrated benefits in reducing opioid overdose mortality.[15,16] However, an oft-repeated criticism of naloxone distribution efforts lies in the idea that naloxone availability enables individuals to use opioids without the fear of death, thereby encouraging high-risk drug use behaviors.[17] A majority of the lay public felt that naloxone was only necessary for people who misuse opioids, and that the availability of naloxone enabled these individuals to increase their opioid use.[12] Lay media reports have perpetuated the idea of "Narcan parties" or "Lazarus parties," where people intentionally use large amounts of opioid to overdose with the expectation that they will subsequently be revived by naloxone administration.[4,5]

Despite the persistence of these views in popular opinion, our data and the available literature contradict the supposition that enhanced availability of naloxone leads to increased opioid use.[1,4,18] Our participants reported no increase in their drug use in spite of widespread availability of naloxone. Instead, they actively attempted to avoid naloxone reversal due to the associated adverse effects and were somewhat reluctant to administer it to others unless they were sure they needed it. Although our sample is small, it consists of a relatively experienced group of people who use opioids, as evidenced by prior treatment attempts for OUD and number of drug-related ED visits. Our preliminary finding that this group did not report adopting riskier drug-use patterns in the context of increased naloxone availability suggests that proliferation of bystander naloxone programs does not beget increased opioid use.

Overall, many of our participants had a high degree of functional knowledge regarding naloxone, held a generally positive view of naloxone, and expressed a willingness to administer naloxone when necessary. Despite traumatic experiences associated with receiving naloxone, participants perceived naloxone as a life-saving medication. Contrary to the popular belief that individuals increase their drug use when naloxone is available, some participants reported that they used less opioids to avoid being administered naloxone. Additionally, our participants described using in groups as a contingency plan to mitigate the risk of overdose, and do not view naloxone as a facilitator of riskier drug use.

Our results suggest several areas that can be targeted to enhance public health interventions. There was widespread thought among participants that the presence of cyanosis ("color change") in an individual is the primary indicator of overdose and the need for naloxone administration. Future naloxone education efforts targeted to PWUD, as well as the lay public, should stress that cyanosis is a late finding and emphasize indicators that differentiate "high" from overdose, such as shallow or slowed breathing. Our participants suggested that visits to needle exchanges and discharges from treatment programs are high-value times to ensure that PWUD are equipped with naloxone. Furthermore, they identified mobile outreach programs as a desirable community-based harm-reduction service. Public health initiatives should also work to address concerns that carrying naloxone may signal unsuccessful recovery, and instead rebrand bystander naloxone as a willingness to save others' lives. It may further be beneficial to increase public awareness that naloxone is not for self-administration.

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