Abstract
Background
The United States is experiencing an intersecting crisis of structural inequities, record levels of homelessness, and a surging fourth wave of the opioid epidemic. People experiencing unsheltered homelessness (PEUH) are at particularly high risk of opioid-related death. Although naloxone is a key tool for preventing overdose fatalities, PEUH face significant barriers to accessing and retaining it. This study examined the acceptability of a novel overdose education and naloxone distribution (OEND) intervention implemented during Kern County’s 2024 Point-in-Time (PIT) unsheltered count. As part of the initiative, volunteers were offered optional OEND training prior to distributing naloxone to PEUH during the annual PIT Count.
Methods
Naloxone distribution was tracked, and PIT Count volunteers were recruited via convenience sampling to complete a post-intervention electronic survey. The survey assessed acceptability using domains from the Theoretical Framework of Acceptability. Descriptive statistics and thematic analysis were used to evaluate responses related to OEND training and naloxone distribution.
Results
Of 111 survey initiators, 94 met eligibility criteria. Most respondents (71.3%) participated in the OEND training, and nearly two-thirds (64.9%) distributed naloxone. Among those with prior overdose experience (n = 26), 88.5% had taken bystander action, most often administering naloxone or calling 911. Training participants reported positive affective attitudes (mean = 1.57), high perceived effectiveness (mean = 1.58), low burden (mean = 1.89), and low opportunity cost (mean = 4.40 on a reverse scale), with slightly lower self-efficacy (mean = 2.23). Overall acceptability was high (mean = 1.45). Among naloxone distributors, responses indicated strong comfort (mean = 1.6), confidence (mean = 1.7), coherence (mean = 1.6), and acceptability (mean = 1.8), along with low burden (mean = 1.9) and opportunity cost (mean = 4.5). Over 87% expressed willingness to distribute naloxone in future PIT Counts. Non-distributors cited reasons such as lack of opportunity, participant refusal, and discomfort. Open-ended responses suggested improvements in training availability, logistics, and messaging for PEUH.
Conclusions
Naloxone training and distribution during the PIT Count was feasible and highly acceptable. These findings support broader implementation to improve naloxone access and reduce overdose deaths among PEUH, and they provide a foundation for future effectiveness studies.
Keywords: Naloxone, Opioid overdose, Persons experiencing unsheltered homelessness, Point in time count, Opioid mortality, Acceptability, Overdose education, Naloxone distribution
Background
While over 1 million people in the United States have died as a result of preventable fatal drug overdoses, [1] persons experiencing homelessness (PEH) are over 30 times more likely to die of a fatal drug overdose than the general population. [2] Moreover, racial disparities in homelessness [3] and opioid-related overdoses [4, 5] are reflected in the acceleration of fatal drug overdoses among Black and Latine people experiencing homelessness compared to their White counterparts. [3] Nationally, over 650,000 reported experiencing homelessness with 39.3% of these individuals experiencing unsheltered homelessness during the single Point-in-Time (PIT) count conducted across the country in January 2023. [6] In 2022, California accounted for 28% of the nation’s unhoused population, totaling to over 181,000 unhoused individuals, and almost one-half (49%) of the nation’s unsheltered population. [7] Furthermore, over two-thirds (68%) of PEH in California were unsheltered—over 123,000 individuals. [7]
Recent studies have shown that access to naloxone, a safe and effective FDA-approved over the counter medication for reversing opioid overdoses, is associated with a 14% decrease in opioid overdoses in the general population and a 23% decrease among Black Americans [8]. Therefore, naloxone engagement and re-engagement with people who use drugs (PWUDs) and who are experiencing homelessness serves as a vital component in the strategy to mitigate opioid-related overdose morbidity and mortality in this population. In addition to syringe service programs, recent strategies implemented to increase access to naloxone and reduce opioid fatalities among PEH in Los Angeles County, include street outreach and distribution, secondary distribution to community groups and county agencies, and setting up naloxone vending machines in the county jails [9]. While overdose deaths remained the leading cause of death for PEH in Los Angeles County, these efforts to increase access to naloxone prevented the death rate from opioid related overdoses from increasing among persons experiencing unsheltered homelessness (PEUH) in the County in 2022 [9]. Unfortunately, the opioid mortality rate among Black people experiencing homelessness continued to significantly increase in Los Angeles County in 2022 [9], which aligns with previous findings that Black people who inject drugs are less likely to receive naloxone compared to their White counterparts [10].
Despite the rising opioid fatality rates and the efficacy of naloxone in reversing overdoses and saving lives, PWUDs, especially those experiencing limited opportunity structures related to poverty and homelessness, experience multiple structural barriers to obtaining and retaining naloxone. [10, 11] For instance, PEUH repeatedly lose access to their naloxone supply due to involuntary displacement practices (e.g. encampment sweeps). [11] A recent study found that being unhoused was negatively associated with currently owning naloxone compared to being housed. [11] To address this disparity, public health researchers have recommended the development and implementation of naloxone scale-up interventions among PEH. [11, 12]
In response to these national and state trends in opioid-related overdoses among PEUH, a local homeless collaborative, the Bakersfield Kern Regional Homeless Collaborative (BKHRC), implemented a novel naloxone distribution intervention during the 2024 PIT Count to expand access to naloxone among PEUH in Kern County, California. Kern County, a large low-density region in Central Valley California, has a fatal drug overdose rate more than twice the statewide average. [13] According to the 2024 PIT Count, the county also experienced a 37% increase in homelessness [14]; however, no specific overdose statistics are reported for people experiencing homelessness. The PIT Count is an annual count of sheltered and unsheltered homelessness on a designated single night during the last 10 days of January conducted by 381 Continuum of Care (CoC) programs throughout the United States. [6, 15] The intervention included two components: (1) optional participation of an in-person or virtual opioid overdose education and intranasal naloxone distribution (OEND) training for PIT Count volunteers, developed by the local substance use prevention coalition; and (2) optional distribution of intranasal naloxone by volunteers to PEUH during the PIT Count. Previous research has shown OEND programs to be safe, cost-effective, and effective in reducing opioid overdose mortality. [16–20]
The primary objective of this pilot study was to assess the retrospective acceptability of OEND training and the subsequent distribution of naloxone during the annual PIT Count amongst volunteers using the Theoretical Framework of Acceptability (TFA) developed by Sekhon and colleagues. [21] The TFA utilizes seven component constructs to assess the prospective, concurrent, or retrospective acceptability of healthcare interventions, including affective attitude, burden, ethicality, intervention coherence, opportunity costs, perceived effectiveness, and self-efficacy (see Table 1 for definitions and descriptions). [19] Previous research has established that assessing the acceptability of an intervention prior to effectiveness studies of the intervention is critical, as acceptable interventions possess a greater likelihood of being implemented. [21, 22] Therefore, the initial step in scaling this intervention was to determine the PIT Count volunteers’ perceptions about of the intervention (e.g. acceptability) to later inform formal ongoing local adoption of the intervention as well as future research on the effectiveness of the intervention and dissemination to other CoCs, which organize and implement PIT Counts nationwide.
Table 1.
Theoretical framework of acceptability domain alignment with evaluation components
Adapted from Sekhon et al. (2017)
| Domains of the theoretical framework of acceptability | OEND training survey items | Naloxone distribution survey items |
|---|---|---|
| Affective Attitude—an individual’s feelings about the intervention | Did you like or dislike the Narcan Training? | How comfortable did you feel using distributing Narcan during the PIT Count? |
| Burden—The perceived effort to participate in the intervention | How much effort did it take to participate in the Narcan Training? | How much effort did it take to distribute Narcan during the PIT Count? |
| Ethicality—The degree to which the intervention aligns with an individual’s values | N/A | How fair is it to distribute Narcan during the PIT Count to unsheltered persons experiencing homelessness? |
| Intervention Coherence—How well the participant understands the intervention and how it works | N/A | It is clear to me how distributing Narcan during the PIT Count will help improve access to Narcan among persons experiencing homelessness |
| Opportunity Costs—How much one needs to forfeit in terms of benefits, profits, or values to participate in the intervention | Participating in the Narcan Training interfered with my other priorities | Distributing Narcan during the PIT Count got in the way of my other priorities for the PIT Count |
| Perceived Effectiveness—The perceived likelihood of the intervention achieving its purpose | The Narcan Training has improved my knowledge of signs of an opioid overdose and how to administer Narcan during an overdose emergency | Distributing Narcan during the PIT Count has improved access to Narcan among persons experiencing homelessness |
| Self-Efficacy—The participant’s belief in their ability to perform the required behaviors from the intervention | How confident do you feel about identifying an opioid overdose emergency and administering Narcan? | How confident do you feel about distributing Narcan during the PIT Count? |
| Overall Acceptability | How acceptable was the Narcan training to you? | How acceptable was distributing Narcan during the PIT Count to you? |
Methods
An electronic quantitative survey informed by the TFA [21] was conducted, with the aim of evaluating the retrospective acceptability of the novel PIT Count naloxone training and distribution initiative among PIT Count volunteers conducted in late January 2024. Participants were recruited through a convenience sample using the BKHRC listserv between February and March 2024. Participants were eligible if they had participated as a volunteer in the 2024 PIT Count in Kern County and aged 18 years and older. Participants who met the inclusion criteria and completed the survey were eligible for a raffle drawing for one of four $50 gift cards.
The survey included written informed consent, inclusion/exclusion screen, and a request for an email address if the participant was interested in entering the raffle drawing. In addition to sociodemographic and intervention participation questions, specific questions related to respondents’ history with witnessing opioid related overdoses and use of bystander responses to overdose emergencies were included. The survey incorporated measures guided by the TFA [21] to assess participants’ agreement with various components of acceptability related to both aspects of the intervention—OEND training prior to the PIT Count and naloxone distribution during the PIT Count (see Table 1). For the OEND training, the survey assessed five TFA domains: affective attitude, burden, perceived effectiveness, self-efficacy, and opportunity costs, along with overall acceptability. [21] For the naloxone distribution initiative, all TFA domains were assessed: affective attitude, burden, ethicality, perceived effectiveness, intervention coherence, self-efficacy, opportunity costs, and overall acceptability. [21] The survey also included items designed to gather feedback on the intervention, such as a Likert-scale statement—“I would be willing to distribute Narcan during the next Kern County PIT Count (2025)”—to assess future willingness; an closed-ended question asking respondents to select reasons for not distributing naloxone, in order to identify barriers to naloxone distribution during the PIT Count; and an open-ended question soliciting suggestions for improvement regarding the intervention.
Participants completed the electronic post-intervention survey independently through Qualtrics. After completing the raffle drawing using the randomizer, the dataset was de-identified and provided to the research team. Study results were shared with the BKHRC and PIT Count Committee, informing refinements to the intervention and supporting its continued implementation and expansion of in-person OEND trainings to rural communities.
Descriptive analyses were conducted in IBM SPSS Statistics (Version 29) to describe the participants’ sociodemographic characteristics as well as the means, standard deviations, and frequencies of the sample’s history of witnessing and responding to opioid overdose emergencies, participation in the PIT Count OEND training and naloxone distribution efforts, the acceptability items for the OEND training and naloxone distribution efforts, and willingness to distribute naloxone at future PIT Counts.
Open-ended survey responses were analyzed using thematic coding. Research team members independently reviewed the qualitative data to systematically identify and categorize recurring themes. Initial codes were developed inductively and then refined through collaborative discussion to ensure consistency and enhance reliability.
The study protocol was reviewed and approved by the California State University, Bakersfield Human Subjects Institutional Review Board (IRB# 25–55).
Results
One hundred eleven respondents initiated the survey; however, only ninety-seven met the eligibility screening requirements. Three (3.1%) of these participants were excluded from the analyses due to discontinued surveys after completing the screening requirements for a final analytic sample of 94. Participant characteristics for the entire sample, the OEND training participants, and the naloxone distribution participants are reported in Table 2.
Table 2.
Descriptive statistics
| All participants | OEND training participants | Naloxone distribution participants | |
|---|---|---|---|
| (n = 94) | (n = 67) | (n = 61) | |
| Mean/SD or percent (n) | Mean/SD or percent (n) | Mean/SD or percent (n) | |
| Participant characteristics | |||
| Gender | |||
| Male | 24.5% (n = 23) | 25.4% (n = 17) | 24.6% (n = 15) |
| Female | 70.2% (n = 66) | 71.6% (n = 48) | 70.5% (n = 43) |
| Non-binary/third gender | 2.1% (n = 2) | 1.5% (n = 1) | 1.6% (n = 1) |
| Prefer not to say | 1.1% (n = 1) | 1.5% (n = 1) | 1.6% (n = 1) |
| Missing | 2.1% (n = 2) | 0.0% (n = 0) | 1.6% (n = 1) |
| Range 24 to 88 years; mean 39.69; SD 12.729 | Range 24 to 77 years; mean 38.20; SD 11.25 | Range 24 to 74 years; mean 39.35; SD 11.01 | |
|---|---|---|---|
| Age | |||
| Race/ethnicity | |||
| White | 36.2% (n = 34) | 35.8% (n = 24) | 41.0% (n = 25) |
| Black | 2.1% (n = 2) | 1.5% (n = 1) | 1.6% (n = 1) |
| Hispanic/Latino(a)/Latinx | 41.5% (n = 39) | 46.3% (n = 31) | 39.3% (n = 24) |
| Asian | 2.1% (n = 2) | 3.0% (n = 2) | 3.3% (n = 2) |
| Hawaiian/Other Pacific Islander | 1.1% (n = 1) | 0.0% (n = 0) | 1.6% (n = 1) |
| American Indian/Alaska Native | 4.3% (n = 4) | 3.0% (n = 2) | 3.3% (n = 2) |
| 2 or More Racial/Ethnic Identities | 8.5% (n = 8) | 7.5% (n = 5) | 4.9% (n = 3) |
| Other | 2.1% (n = 2) | 3.0% (n = 2) | 3.3% (n = 2) |
| Missing | 2.1% (n = 2) | 0.0% (n = 0) | 1.6% (n = 1) |
| Occupational setting | |||
| Behavioral health | 17.0% (n = 16) | 20.9% (n = 14) | 19.7% (n = 12) |
| Social services | 24.5% (n = 23) | 22.4% (n = 15) | 18.0% (n = 11) |
| Healthcare | 10.6% (n = 10) | 11.9% (n = 8) | 14.8% (n = 9) |
| Government agency | 13.8% (n = 13) | 14.9% (n = 10) | 18.0% (n = 11) |
| Child welfare | 2.1% (n = 2) | 1.5% (n = 1) | 1.6% (n = 1) |
| Older adult services | 1.1% (n = 1) | 0.0% (n = 0) | 0.0% (n = 0) |
| Faith-based organization | 5.3% (n = 5) | 4.5% (n = 3) | 6.6% (n = 4) |
| Other | 23.4% (n = 22) | 23.9% (n = 16) | 19.7% (n = 12) |
| Missing | 2.1% (n = 2) | 0.0% (n = 0) | 1.6% (n = 1) |
| Years of participation in the PIT count | |||
| 1 Year | 55.3% (n = 52) | 58.2% (n = 39) | 57.4% (n = 35) |
| 2 Years | 20.2% (n = 19) | 22.4% (n = 15) | 19.7% (n = 12) |
| 3 Years | 13.8% (n = 13) | 13.4% (n = 9) | 11.5% (n = 7) |
| 4+ Years | 8.5% (n = 8) | 6.0% (n = 4) | 9.8% (n = 6) |
| Missing | 2.1 (n = 2) | 6% (n = 4) | 1.6% (n = 1) |
| All participants Mean/SD or percent (n) |
|
|---|---|
| Overdose management history | |
| Witnessed an overdose | |
| Yes | 66.0% (n = 62) |
| No | 27.7% (n = 26) |
| Prefer not to say | 2.1% (n = 2) |
| Missing | 4.3% (n = 4) |
| Number of times witnessed an OD | |
| Range 1 to 6; mean 2.21; SD 1.619 | |
| Overdose response strategies | |
| Gave them naloxone | 19 |
| Called 911 | 20 |
| Physical stimulation | 6 |
| Chest compressions | 5 |
| Mouth-to-mouth resuscitation/CPR | 3 |
| Cold water or ice | 4 |
| Did something else (other) | 2 |
| Number of times administered naloxone in the past year | |
| Range from 0 to 3; mean 1.29; SD.951 | |
| Participation in the intervention | |
| Participated in the PIT count OEND training | |
| Yes | 71.3% (n = 67) |
| No | 25.5% (n = 24) |
| Missing | 3.2% (n = 3) |
| Distributed naloxone during the PIT Count | |
| Yes | 64.8% (n = 61) |
| No | 28.7% (n = 27) |
| Missing | 6.4% (n = 6) |
| Number of naloxone kits distributed during the PIT Count | |
| Range 1 from 40; mean 8.59; SD 8.456 | |
| Willingness to distribute naloxone at future PIT counts | |
| Strongly agree | 69.1% (n = 65) |
| Somewhat agree | 13.8% (n = 13) |
| Neither agree nor disagree | 5.3% (n = 5) |
| Somewhat disagree | 1.1% (n = 1) |
| Strongly disagree | 6.4% (n = 6) |
| Missing | 4.5% (n = 4) |
| Reasons for not distributing naloxone during the PIT count (n = 24) | |
| None of the PIT Count survey participants wanted Narcan | 50.0% (n = 12) |
| I did not have time to distribute Narcan to PIT Count survey participants due to amount of surveys I needed to complete during the PIT Count | 4.2% (n = 1) |
| Other members of my team distributed Narcan, but I did not have an opportunity to distribute it | 33.3% = (n = 8) |
| I was not comfortable distributing Narcan to PIT Count survey participants | 8.3% (n = 2) |
| I did not feel confident providing information about how to use Narcan to PIT Count survey participants | 4.2% (n = 1) |
Over one-quarter of respondents (n = 26) stated that they previously witnessed an opioid related overdose emergency with most of these respondents (88.5%) indicating that they engaged in a bystander intervention to support the overdose victims. Fifteen of these respondents reported that they employed multiple bystander interventions. The most popular bystander interventions included administering naloxone (n = 15), calling 911 (n = 14), and physical stimulation (n = 6). For the 19 respondents who reported the number of opioid overdose emergencies they witnessed, they witnessed an average of 2.21 overdose emergencies (range 1 to 6; standard deviation [SD] 1.619). Of the 7 respondents who indicated the number of times they previously administered naloxone to an overdose victim, they administered naloxone 1.29 times on average (range 0 to 3; mean 1.29) (see Table 2).
Over two-thirds of respondents (n = 67) reported that they participated in the OEND training opportunity. Sixty-five respondents reported the type of training they attended—22 attended the in-person training and 43 viewed the asynchronous video training.
The 65 respondents who participated in the OEND training indicated their level of agreement with each statement corresponding to five of the components of the TFA. [21] For affective attitude, 61.5% of respondents (n = 40) reported that they liked the training “a great deal,” and another 23.1% (n = 15) responded they liked the training “somewhat” (average score of 1.57 on a 5-point scale, with a lower score indicating more positive affective attitudes toward the intervention). In terms of burden, 40% of respondents (n = 26) stated that it took no effort to participate, and another 44.6% (n = 29) indicated that it took “a little effort” (average score of 1.89 on a 5-point scale, with lower scores representing lower levels of burden required to participate in the intervention). Similarly, 47 respondents (70.1%) reported a low opportunity cost associated with participating in the training, with most strongly disagreeing that “Participating in the Narcan Training interfered with my other priorities” (average score of 4.40 on a reverse 5-point scale, with higher scores indicating lower opportunity costs required to participate in the intervention). Additionally, respondents reported a high level of perceived effectiveness of the naloxone training with 60% (n = 39) strongly agreeing and 30.8% (n = 20) somewhat agreeing with the statement, “The Narcan Training has improved my knowledge of signs of an opioid overdose and how to administer Narcan during an overdose emergency” (average score of 1.58 on a 5-point scale, with lower scores reflecting stronger beliefs that the intervention achieved its intended purpose). However, respondents reported a respectively lower level of agreement related to self-efficacy with over one quarter (n = 17) stating that they were “very confident"and slightly over half (n = 34) reporting that they were “confident” (average score of 2.23 on a 5-point scale, with lower scores indicating greater confidence in performing the behavior required to participate in the intervention) with “identifying an opioid overdose emergency and administering naloxone.” Overall, the OEND training was regarded as highly acceptable among the respondents with all reporting it was completely acceptable (n = 41), acceptable (n = 19), or no opinion (n = 5) (average score of 1.45 on a 5-point scale, with lower scores reflecting greater overall acceptability of the intervention) (see Table 3).
Table 3.
Descriptive statistics for OEND training acceptability measures
| OEND training acceptability measures | Mean/SD or percent (n) |
|---|---|
| Did you like or dislike the Narcan training? (affective attitude) | |
| Like a great deal | 61.5% (n = 40) |
| Like somewhat | 23.1% (n = 15) |
| Neither like nor dislike | 13.8% (n = 9) |
| Dislike somewhat | 0.0% (n = 0) |
| Dislike a great deal | 1.5% (n = 1) |
| How much effort did to take to participate in the Narcan training? (burden) | |
| None at all | 40.0% (n = 26) |
| A little effort | 44.6% (n = 29) |
| No opinion | 7.7% (n = 5) |
| A lot of effort | 1.5% (n = 1) |
| A great deal of effort | 6.2% (n = 4) |
| The Narcan training has improved my knowledge of signs of an opioid overdose and how to administer Narcan during an overdose emergency. (perceived effectiveness) | |
| Strongly agree | 60.0% (n = 39) |
| Somewhat agree | 30.8% (n = 20) |
| Neither agree nor disagree | 3.1% (n = 2) |
| Somewhat disagree | 3.1% (n = 2) |
| Strongly disagree | 3.1% (n = 2) |
| How confident do you feel about identifying an opioid overdose emergency and administering Narcan? (self-efficacy) | |
| Very confident | 26.2% (n = 17) |
| Confident | 52.3% (n = 34) |
| No opinion | 3.1% (n = 2) |
| Unconfident | 9.2% (n = 6) |
| Very unconfident | 9.2% (n = 6) |
| Participating in the Narcan training interfered with my other priorities. (opportunity costs) | |
| Strongly agree | 3.1% (n = 2) |
| Somewhat agree | 4.6% (n = 3) |
| Neither agree nor disagree | 13.8% (n = 9) |
| Somewhat disagree | 6.2% (n = 4) |
| Strongly disagree | 72.3% (n = 47) |
| How acceptable was the Narcan training to you? (general acceptability) | |
| Completely acceptable | 63.1% (n = 41) |
| Acceptable | 29.2% (n = 19) |
| No opinion | 7.7% (n = 5) |
| Unacceptable | 0.0% (n = 0) |
| Completely unacceptable | 0.0% (n = 0) |
Almost two-thirds of the respondents (n = 61) reported that they distributed naloxone during the 2024 PIT Count. Of these respondents, 58 shared the number of naloxone kits they distributed during the 2024 PIT Count with an average of 8.59 kits distributed (range 1 to 40; SD 8.456) (see Table 2).
Respondents who distributed naloxone during the unsheltered PIT Count reported their level of agreement related to all seven components of the TFA. [21] To assess affective attitude toward naloxone distribution during the PIT Count, respondents reported varying levels of comfort with 56.7% (n = 34) reporting they were “extremely comfortable,” 10% (n = 6) “somewhat comfortable,” 13.3% (n = 8) neutral, 11.7 (n = 7) “somewhat uncomfortable,” and 8.3% (n = 5) “extremely uncomfortable” (average of 1.6 on a 5-point scale, with lower scores reflecting greater comfort with participating in the intervention). However, the respondents reported a high level of self-efficacy for the intervention with 83.6% (n = 51) rating themselves as “confident” to “very confident” and only 5% (n = 3) reporting they were “unconfident” or “very unconfident” (average of 1.7 on a 5-point scale, with lower scores corresponding to greater confidence in performing the behavior required to participate in the intervention). In terms of burden, most of these respondents (n = 51; 83.6%) reported that distributing naloxone took “little” to “no effort at all” (average of 1.9 on a 5-point scale, with lower scores indicating lower levels of burden required to participate in the intervention). Moreover, most respondents (n = 50; 83.3%) reported a low opportunity cost for participating in the intervention and disagreed or strongly disagreed with the statement, “Distributing Narcan during the PIT Count got in the way of my other priorities for the PIT Count” (average of 4.5 on a reverse 5-point scale, with higher scores representing lower opportunity costs required to participate in the intervention). For ethicality, many respondents who distributed naloxone rated the intervention as “fair” (n = 17; 28.3%) or “very fair” (n = 34; 56.7%) (average 1.7 on a 5-point scale, with lower scores corresponding to greater alignment between the intervention and the participant’s values). Respondents also rated the intervention highly for perceived effectiveness with over three-quarters strongly to somewhat agreeing that it improved access to naloxone among PEUH (n = 47; average of 1.8 on a 5-point scale, with lower scores reflecting stronger beliefs that the intervention achieved its intended purpose). Similarly, the respondents also reported a high level of intervention coherence with 61.7% (n = 37) strongly agreeing and one-quarter (n = 15) somewhat agreeing with the statement, “It is clear to me how distributing Narcan during the PIT Count will help improve persons access to Narcan among persons experiencing homelessness” (average of 1.6 on a 5-point scale, with lower scores indicating stronger agreement that the intervention was likely to achieve its intended purpose). Importantly, over three-quarters of these respondents (n = 46) reported that the intervention generally was either acceptable or completely acceptable to them (average of 1.8 on a 5-point scale, with lower scores reflecting greater overall acceptability) (see Table 4).
Table 4.
Descriptive statistics for naloxone distribution acceptability measures
| Naloxone distribution acceptability measures | Mean/SD or percent (n) |
|---|---|
| How comfortable did you feel distributing Narcan during the PIT Count? (affective attitude) | |
| Extremely comfortable | 56.7% (n = 34) |
| Somewhat comfortable | 10.0% (n = 6) |
| Neither comfortable nor uncomfortable | 13.3% (n = 8) |
| Somewhat uncomfortable | 11.7% (n = 7) |
| Extremely uncomfortable | 8.3% (n = 5) |
| How much effort did it take to distribute Narcan during the PIT Count? (burden) | |
| None at all | 45.8% (n = 27) |
| A little effort | 40.7% (n = 24) |
| No opinion | 3.4% (n = 2) |
| A lot of effort | 8.5% (n = 5) |
| A great deal of effort | 1.7% (n = 1) |
| How fair do you believe it is to distribute Narcan during the PIT Count to unsheltered persons experiencing homelessness? (ethicality) | |
| Very fair | 56.7% (n = 34) |
| Fair | 28.3% (n = 17) |
| No opinion | 10.0% (n = 6) |
| Unfair | 0.0% (n = 0) |
| Very unfair | 5.0% (n = 3) |
| Distributing Narcan during the PIT Count has improved access to Narcan among persons experiencing homelessness. (perceived effectiveness) | |
| Strongly agree | 53.3% (n = 32) |
| Somewhat agree | 25.0% (n = 15) |
| Neither agree nor disagree | 15.0% (n = 9) |
| Somewhat disagree | 1.7% (n = 1) |
| Strongly disagree | 5.0% (n = 3) |
| It is clear to me how distributing Narcan during the PIT Count will help improve persons access to Narcan among persons experiencing homelessness. (intervention coherence) | |
| Strongly agree | 61.7% (n = 37) |
| Somewhat agree | 25.0% (n = 15) |
| Neither agree nor disagree | 10.0% (n = 6) |
| Somewhat disagree | 1.7% (n = 1) |
| Strongly disagree | 1.7% (n = 1) |
| How confident do you feel about distributing Narcan during the PIT Count? (self-efficacy) | |
| Very confident | 50.0% (n = 30) |
| Confident | 35.0% (n = 21) |
| No opinion | 10.0% (n = 6) |
| Unconfident | 1.7% (n = 1) |
| Very unconfident | 3.3% (n = 2) |
| Distributing Narcan during the PIT Count got in the way of my other priorities for the PIT Count. (opportunity cost) | |
| Strongly agree | 1.7% (n = 1) |
| Somewhat agree | 1.7% (n = 1) |
| Neither agree nor disagree | 13.3% (n = 8) |
| Somewhat disagree | 10.0% (n = 6) |
| Strongly disagree | 73.3% (n = 44) |
| How acceptable was distributing Narcan during the PIT Count to you? (general acceptability) | |
| Completely acceptable | 53.3% (n = 32) |
| Acceptable | 26.7% (n = 16) |
| No opinion | 15.0% (n = 9) |
| Unacceptable | 0.0% (n = 0) |
| Completely unacceptable | 5.0% (n = 3) |
Of the 33 respondents who did not distribute naloxone during the unsheltered PIT count, 24 reported the reason that they did not participate in this aspect of the intervention. Half of these respondents (n = 12) indicated that PIT Count survey participants they interacted with declined the naloxone kit. One third (n = 8) stated that while other members of their assigned PIT Count team distributed naloxone, they did not have an opportunity to distribute it. Two respondents reported that their affective attitude (comfort) dissuaded them from distributing naloxone during the PIT Count. One respondent attributed their lack of self-efficacy in providing information about how to use naloxone, and another related to opportunity cost and lack of time to distribute naloxone and complete the surveys during the PIT Count as reasons for abstaining from naloxone distribution (see Table 4).
Ninety respondents indicated their level of agreement with the statement, “I would be willing to distribute Narcan during the next Kern County PIT Count (2025).” Over 87% of these participants indicated that they somewhat agreed (n = 13) to strongly agreed (n = 66) with only 6 somewhat disagreeing (n = 1) to strongly disagreeing (n = 5) (average of 1.51 on a 5-point scale) (see Table 2).
In open-ended responses about suggestions for improving the naloxone training and distribution efforts during the PIT Count, several key themes emerged. These included feedback on the OEND training itself, the quantity of naloxone kits provided to volunteer teams, additional supplies needed for distribution, and support for messaging and training with PEUH during the Count. Regarding OEND training, respondents expressed a desire for more in-person training sessions, making the training mandatory or universal for all volunteers, offering sessions throughout the year, and providing refresher demonstrations on naloxone administration the morning of the PIT Count at headquarters. Several respondents indicated that teams should be allocated a greater quantity of naloxone at the start of the PIT Count, as they quickly ran out and experienced delays in obtaining more from the central headquarters. Some respondents also stated that it would be more expedient to provide each volunteer with a tote bag/backpack of naloxone rather than providing the box of 12 to the team. Another respondent suggested that the naloxone be included as a standard item in each of the hygiene bags distributed to PIT Count survey participants, eliminating the opt-in approach for volunteers and survey participants. Other supplies requested by respondents included latex gloves and CPR shields to enhance their ability to respond to an overdose emergency during the PIT Count. Finally, the respondents requested support with messaging for PEUH about the value of naloxone to save the life of others rather than an indication about whether one is actively engaged in substance use as well as field demonstrations for PEUH on how to administer naloxone.
Discussion
The current study aimed to determine the acceptability of a novel approach to expanding access to naloxone among PEUH by providing an optional OEND training to PIT Count volunteers and opportunity for distribution of naloxone kits to PEUH during an annual PIT Count. Additionally, this study is the first to evaluate the acceptability of OEND training and naloxone distribution during an annual PIT Count. The results of this study strengthen the emerging support for the acceptability of implementing OEND training and naloxone distribution efforts during annual PIT Counts to increase access to naloxone among PEUH and reduce preventable opioid related overdose fatalities among this population with multiple vulnerabilities.
Both the OEND training and naloxone distribution components of the intervention were acceptable to the PIT Count volunteers, as demonstrated by strong ratings on their respective acceptability measures and a high reported willingness to participate again in the future. Using the TFA to guide a retrospective assessment of the acceptability of the PIT Count OEND training and naloxone distribution initiative highlighted potential factors contributing to acceptability of this low-cost, low-barrier novel intervention among PIT Count volunteers. For the OEND training, most participants perceived there to be limited opportunity costs and burden, as this brief training was embedded within the mandatory PIT Count training provided to volunteers. This result aligns with findings from Brandt et al. [23] regarding the impact of the timeframe on participants’ acceptability of OEND and supported as an evidence-based practice from studies reporting that brief trainings have been adequate to impart basic knowledge of overdose management [19, 24]. While most participants reported that they liked the training (affective attitude) and that it increased their ability to recognize the signs of an opioid overdose emergency and administer naloxone (perceived effectiveness), they rated their self-efficacy the lowest out of all acceptability response items. Previous research has shown that OEND training enhances participants’ knowledge of overdose management [24–32], which aligns with the present study’s findings related to perceived effectiveness. However, these studies also indicate that OEND training improves participants’ confidence (self-efficacy) in overdose management [24–32]. While our participants provided retrospective scoring of the self-efficacy item post-intervention, this study did not include pre-test and post-test measures to assess improvements in participants’ knowledge and confidence in overdose management. Overall, this component of the intervention was also perceived as highly acceptable among respondents. These findings about the acceptability of the OEND training coincide with a previous study of OEND trainings, in which trainees reported that the intervention was highly acceptable [23].
For the naloxone distribution during the PIT Count, the participants also reported limited to no opportunity costs and burden associated. Since PIT Count volunteers already devote time to engaging with PEUH and distributing supplies during the annual PIT Count, offering naloxone to PEUH during their usual duties was not perceived to increase the amount of effort or interfere with their priorities during the PIT Count. Most respondents also perceived naloxone distribution among PEUH to be fair, coherent, and effective in increasing access to naloxone among PEUH. While self-efficacy for distributing naloxone was high, affective attitude (comfort) was lower for distributing naloxone to PEUH during the PIT Count. Future qualitative research should explore volunteers’ affective attitudes regarding the intervention to inform strategies to foster engagement with naloxone distribution efforts during the PIT Count. Overall, participants in this component of the intervention perceived naloxone distribution to PEUH during the PIT Count to be highly acceptable. To our knowledge, this is the first study to explore the acceptability of naloxone distribution strategies among community members engaged in outreach efforts with PEUH.
As respondents noted in the open-ended response field, additional supplies were needed to enhance the comfort of volunteers in distributing naloxone and responding to opioid overdose emergencies during the PIT Count. Furthermore, respondents also requested more training for the messaging around naloxone and demonstrating naloxone administration to PEUH during the PIT Count. Incorporating these elements into future iterations of the intervention may address concerns related to their self-efficacy with overdose management and affective attitude (comfort) with naloxone distribution during the PIT Count.
Despite the above discussed positive outcomes of this study and its novel contributions to current OEND interventions among PEUH, it was not without limitations. First, as a pilot study, no definitive conclusions about efficacy could be made. The focus of the current study was to assess the acceptability of this intervention among PIT Count volunteers and to provide strong preliminary data for an effectiveness study.
Second, one of the central goals for this novel naloxone distribution initiative was to increase access to naloxone among PEUH. While the study tracked the number of naloxone kits distributed (n = 591), it neither recorded the number of PEUH who obtained naloxone nor their sociodemographic characteristics. Additionally, this study was unable to assess the acceptability of this intervention among PEUH and its impact on improving disparities in the naloxone cascade, creating gaps in our understanding of the targeted recipients’ perceptions, satisfaction, and uptake of the intervention.
Third, our sample was small. While 94 respondents met the eligibility criteria to participate in the survey, about two-thirds of respondents reported that they completed the OEND training and distributed naloxone during the PIT Count, respectively. Another limitation involved the use of a convenience sample approach. Even though our sample was diverse, it was unknown whether it is representative of the larger PIT Count volunteer population across the country.
A fifth limitation was that the high rating of acceptability for the OEND training and naloxone distribution during the PIT Count might have been the result of selection bias. Due to the design of our opt-in nature of the OEND training and naloxone distribution during the PIT Count, only participants who completed the OEND training and participated in naloxone distribution during the PIT Count were able to rate the acceptability of these elements of the intervention. The acceptability of OEND training and naloxone distribution during the PIT Count might have been lower among those PIT Count volunteers who did not self-select to participate in the intervention.
Finally, our results were specific to the BKRHC CoC and PIT Count volunteers in Kern County. Barriers to providing OEND training and naloxone kits may vary depending on the resources of the local CoC and number of volunteers and PEUH. For instance, smaller rural areas may lack access to competent OEND trainers and may not have an adequate supply of naloxone to distribute. Conversely, municipalities with a high volume of PEUH, like Los Angeles County, may experience difficulties scaling this intervention to provide OEND training to the numerous volunteers and amassing a large quantity of naloxone kits for their volunteers to distribute.
Even considering these limitations, this study was the first to explore the acceptability of a novel low-cost, low-barrier naloxone distribution intervention targeting PEUH that could support future inquiry to the efficacy of this intervention. Overall, by exploring the effectiveness of this approach through continued research, naloxone engagement among PEUH could improve, resulting in a decrease of preventable overdose fatalities amongst this population.
Conclusions
There is an emphasis on developing novel approaches to improving naloxone cascades among PEUH to reduce opioid overdose fatalities among this population, especially Black and Latine persons. Examining the acceptability of these interventions is imperative to increase the widespread adoption of these approaches. Our findings may guide future dissemination and implementation of OEND training and naloxone distribution efforts during PIT Counts across CoCs in the United States, enhancing access to life-saving naloxone among unhoused persons who are the most likely to experience or witness a preventable opioid-related overdose death. Additional research on the effectiveness of this intervention may be required to evaluate the delivery and outcomes of the intervention.
Acknowledgements
The authors would like to acknowledge the support and cooperation of the Bakersfield Kern Regional Homeless Collaborative (BKRHC), Kern Behavioral Health and Recovery Services (KernBHRS) Prevention Team, and California State University, Bakersfield (CSUB) – Department of Social Work. A special thanks to Rick Ramos, Mary Scott, Manuel Vieyra, Destiny Reveles, Jamie Bowman, Maribel Bautista-Vega, and the 2024 PIT Count volunteers. The authors also recognize the lives lost to preventable opioid overdose fatalities in their community.
Abbreviations
- CoC
Continuum of care
- PEH
Persons experiencing homelessness
- PEUH
Persons experiencing unsheltered homelessness
- PIT
Point-in-time
- PWUD
Person(s) who use drug(s)
- OEND
Overdose education and naloxone distribution
- TFA
Theoretical framework of acceptability
- BKRHC
Bakersfield Kern Regional Homeless Collaborative
Biographies
Ashleigh Herrera
is an Assistant Professor in the Department of Social Work at California State University, Bakersfield. She is a Licensed Clinical Social Worker (LCSW) and has been practicing since 2012. AH is also the CEO and Founder of HOPE in the Valley, a syringe service program (SSP) in Kern County, and provides field supervision and training for Master of Social Work students to increase their competence and confidence with evidence-based harm reduction practices to empower PWUDs and people engaged in sex work to save their own lives. AH is a member of the BKHRC and Drug Free Kern.
Kael Rios
is an Associate Clinical Social Worker (ASW).
Author contributions
AH designed the study, analyzed and interpreted the data, and wrote the first draft of the manuscript. KR contributed to the original design of the study and provided support in the data analysis process. All authors contributed to the revision of the manuscript and read and approved the final manuscript.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.
Availability of data and materials
No datasets were generated or analysed during the current study.
Declarations
Ethics approval and consent to participate
This study was approved by California State University, Bakersfield’s Human Subjects Institutional Review Board, #25-55.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Data Availability Statement
No datasets were generated or analysed during the current study.