Overdose Education and Naloxone Distribution: An Evidence-Based Practice That Warrants Course Correcting

In this issue of AJPH, Freeman et al.’s study “Effect of the Communities That HEAL Intervention on Overdose Education and Naloxone Distribution: A Cluster Randomized Wait-List Controlled Trial” (p. 83) is the largest analysis of a well-funded, broadly supported, bipartisan, popular initiative: overdose education and naloxone distribution (OEND). We were pleased to see affirmation of the study hypothesis that well-resourced Communities That HEAL (CTH) intervention communities will distribute, overall, significantly higher rates of naloxone units compared with less well-resourced and less-participatory initiatives (i.e., usual care).

The large budget and a research component make OEND via the HEALing Communities Study unique. Nonetheless, in response to increasing numbers of opioid-involved polydrug overdoses, an expansion of community-based naloxone provision is a shared experience across the country, albeit at rates related to resource investment.

Unfortunately, a considerable majority of the expansion efforts—including certain components of the HEALing Communities Study—have strayed from the existing evidence base. The evidence base for broader bystanders and passive distribution is minimal and would not be expected to affect overdose mortality rates directly. Conflating evidence-based OEND and general community-based naloxone provision can be disingenuous and dangerous, especially when making resource allocation decisions.

OEND as an evidence-based practice refers to three very specific models: (1) naloxone distribution directly to people who use drugs (PWUD) via syringe services programs (SSPs),¹ (2) naloxone provision upon release from incarceration,² and (3) coprescribing naloxone with opioids to people at high risk.³

However, there is a measurable implementation gap between community-based naloxone provision and evidence-based OEND. Remedy Alliance is a nonprofit wholesale distributor of naloxone to SSPs, harm reduction programs, and state and municipal government programs that are prioritizing SSPs with the naloxone they purchase and that are operating with fidelity to the evidence base.⁴ Using a tiered pricing system, better-resourced customers pay a higher price than the partially funded programs, and unfunded entities are eligible for naloxone at no cost. There are nearly 500 programs—representing all but three states—that order naloxone from Remedy Alliance, which has sent out 3.4 million doses since August 2022, a considerable majority of which were injectable naloxone.

Figure 1 shows the number of doses sent to programs in each state or territory, including the number and percentage sent at no cost from August 2022 to August 2024. The states that received more than 100 000 doses are Minnesota, North Carolina, Washington, Arizona, Missouri, Indiana, Illinois, Wisconsin, Georgia, and Oregon. The states and territories that received more than 90% of the naloxone at no cost include Alabama, Alaska, Hawaii, Louisiana, Massachusetts, Mississippi, Nebraska, New York, Puerto Rico, Tennessee, and Virginia. (For data on all states and territories, see Table A, available as a supplement to the online version of this article at http://www.ajph.org.) By keeping in mind these otherwise unpublished data, which are unaccounted for in other data sets, future research might consider a wide range of hypotheses:

• Hypothesis 1. Higher proportions of no-cost naloxone are negatively associated with government investment in evidence-based OEND.

• Hypothesis 2. Higher numbers of naloxone doses are positively associated with governmental investment in expensive nasal naloxone products only.

• Hypothesis 3. States with a direct purchase agreement with Remedy Alliance will have a significantly higher volume of naloxone sent to the state.

FIGURE 1—

Total Naloxone Doses and No-Cost Naloxone Shipped to US States or Territories by Remedy Alliance: August 2022–August 2024

Note. Each circle represents a US state or territory. Along the vertical axis is total volume of naloxone. Along the horizontal axis is percentage free or at no cost to the organizations or health departments. Red circles represent the highest volume of no-cost naloxone, and darker green circles represent states that received a lower volume of no-cost naloxone.

Hypothesis 1 may be influenced by SSPs needing more naloxone than their state or municipality provides. Hypothesis 2 could be influenced by naloxone budget lines that are depleted before the end of the fiscal year, causing gaps in naloxone access for SSPs, or perhaps SSPs want an injectable naloxone offering but are unable to acquire it from state sources. Hypothesis 3 may be influenced by local stigma or restrictive state level systems.

DILUTION OF THE IMPACT OF NALOXONE DISTRIBUTION

In 2013, OEND was confirmed to be an evidence-based practice that reduces fatal opioid overdose, but there was not explicit national federal funding for naloxone until the 2017 rollout of the 2016 CARA Act.⁵ When federal funding did become available, it was considerable and rapidly disseminated. As more dollars became available, public health infrastructures expanded, the dedicated workforce drastically increased, and competing interests emerged.

Two competing interests influence community naloxone access. The first is the marketing of new products. This includes the emergence of branded and more expensive naloxone products and also adjacent markets like vending machines, naloxone display boxes, drug disposal packets, “fentanyl protection products,” and others that rapidly enter the landscape. These entities are engaged in marketing practices that are compelling to the decision-makers who are inexperienced in resource allocation and evidence-based OEND.

The second category of interests that influence community naloxone access is a sociological inevitability of an ongoing overdose epidemic: broader investment from groups of people with a personal or professional interest in the topic. Freeman et al. describe the first component of the CTH intervention as “a coalition-driven community engagement process to select and support the implementation of strategies to facilitate the uptake of EBPs [evidence-based practices].” For any public health problem, this is an excellent strategy to ensure broad support at a community level. However, an unintended outcome of this coalition-based decision-making is that the voice, needs, and priorities of SSPs and PWUD have become just one of many. Indeed, the originators of the OEND evidence-based intervention are minimally included at best and frequently disregarded completely in “coalition-driven community engagement process[es].”

OPPORTUNITIES FOR COURSE CORRECTION

There are several strategies that resource allocation decision-makers can consider to better align efforts with the OEND evidence base.

Investing in a mix of different naloxone products, including inexpensive generic injectable versions, can help maintain budgets while increasing volume. Spending half a budget on nasal and half on injectable would result in a 36% greater volume of naloxone than nasal alone.

SSPs should be fully resourced, with as much naloxone as they need to develop an abundance mindset that allows organizations to confidently provide as much naloxone as PWUD request. Importantly, SSPs also need funding for staff time for OEND to capitalize on existing social networks by encouraging secondary distribution through drug-using social networks. In the HEALing Communities Study, this practice successfully included paying PWUD to attend to their social networks’ naloxone access needs.⁶

To reach people who use drugs by routes other than injection, and to expand the reach of trusted harm reduction services, it is necessary to provide services and supplies that PWUD want.⁷ Examples include smoking supplies, snorting supplies, advanced technology drug-checking services, overdose prevention centers, food, and toiletries.

Finally, states and municipalities should triage requests for naloxone in a way that ensures that the venues and organizations most likely to use the naloxone are well stocked.⁸ We have numerous examples of historical experiences with this type of rollout; we can look to the prioritization scheme that was deployed with COVID-19 vaccination eligibility as a recent example.

Although there are some excellent and exciting OEND adaptations, there are also some adaptations that deviate dramatically from the evidence base, and those resources may be better directed elsewhere. We applaud adaptation and innovation in public health, particularly for people who have had tenuous or even harmful interfaces with medical, mental, and public health services—for example, people who use drugs, people experiencing homelessness, people who do sex work, and Black, Indigenous, and Latine people. At the same time, the urgency of the overdose crisis demands that the evidence-based models (OEND via SSPs) be fully resourced to achieve maximum benefit.