Abstract
This cross-sectional study describes the level of naloxone information and availability and general attitudes about illicit drug use across different demographic groups in the US.
Introduction
Naloxone and other opioid overdose reversal medications can save lives when given in time.1 Despite increases in pharmacy-dispensed naloxone,2 additional naloxone distribution is needed through both community-based and pharmacy sources.3 Reported barriers include cost, stigma, and lack of knowledge and training related to naloxone access and use.4 The objective of this study was to analyze US adults’ awareness of and beliefs about naloxone and its availability.
Methods
Data were obtained from round 2 (collected October-November 2023) of the National Center for Health Statistics Rapid Surveys System. Estimates were weighted to be nationally representative.5 This activity was reviewed by the Centers for Disease Control and Prevention (CDC), deemed research not involving human participants, and conducted consistent with applicable federal law and CDC policy.
Whether adults had heard of naloxone, whether they currently carried naloxone, and their reasons for not carrying naloxone were analyzed overall and by demographic characteristics. Estimates of whether adults currently carried naloxone, were aware of naloxone’s availability, and agreed with naloxone availability in various locations were analyzed overall and stratified by their agreement or disagreement that persons are to blame for their drug use.
SAS, version 9.4 (SAS Institute), was used for analyses, and survey weights were applied. Two-sided P < .05 was considered statistically significant.
Results
A total of 7046 adults (3796 female [weighted 51.2%]) responded to the 2023 survey. Overall, 71.0% of adults reported having heard of naloxone, of whom 5.6% currently carried naloxone (Table 1). Older adults, females, those with higher educational level, those residing in nonmetropolitan areas, and those with higher household incomes had a higher prevalence of having heard of naloxone, whereas adults of Hispanic, non-Hispanic Black, and other race and ethnicity and those residing in the South and West had a lower prevalence. Adults 65 years or older, those with a bachelor’s degree, and those with higher household incomes reported a lower prevalence of carrying naloxone, while Hispanic adults reported a higher prevalence. Reasons reported for not carrying naloxone included not thinking it works (9.2%), not knowing how to use it (60.1%), and not knowing where to get it (67.3%); significant differences by demographic characteristics were found.
Table 1. Awareness of Naloxone and Factors Associated With Carrying Naloxone by Demographic Characteristicsa.
| Characteristic | Adults, weighted % (95% CI) | ||||
|---|---|---|---|---|---|
| Heard of naloxone/Narcan (unweighted n = 7016) | Currently carry naloxone/Narcan (unweighted n = 5258)b | Why do you think people do not carry naloxone/Narcan?c | |||
| Do not think it works (unweighted n = 4778)c | Do not know how to use it (unweighted n = 4821)c | Do not know where to get it (unweighted n = 4834)c | |||
| Overall | 71.0 (69.6-72.4) | 5.6 (4.8-6.4) | 9.2 (8.2-10.2) | 60.1 (58.4-61.8) | 67.3 (65.6-68.9) |
| Age group, y | |||||
| 18-34 [Reference] | 63.2 (59.9-66.4) | 7.4 (5.6-9.7) | 10.8 (8.5-13.6) | 68.2 (64.3-72.0) | 74.5 (70.8-78.0) |
| 35-49 | 70.6 (67.8-73.3)d | 7.1 (5.3-9.3) | 7.5 (5.8-9.5)d | 59.8 (56.3-63.3)d | 68.7 (65.2-72.0)d |
| 50-64 | 74.2 (71.7-76.5)d | 5.6 (4.2-7.3) | 8.5 (6.7-10.5) | 55.2 (51.9-58.5)d | 64.0 (60.8-67.1)d |
| ≥65 | 78.3 (76.0-80.5)d | 2.1 (1.3-3.1)d | 9.8 (8.1-11.8) | 57.0 (54.0-59.9)d | 61.8 (58.8-64.6)d |
| Sex | |||||
| Male [reference] | 68.9 (66.8-71.0) | 6.0 (4.8-7.4) | 8.5 (7.1-10.0) | 56.9 (54.4-59.4) | 64.0 (61.5-66.4) |
| Female | 73.1 (71.2-74.9)d | 5.2 (4.2-6.3) | 9.8 (8.5-11.3) | 63.0 (60.7-65.3)d | 70.2 (68.0-72.4)d |
| Race and ethnicitye | |||||
| Black, non-Hispanic | 62.8 (58.1-67.4)d | 6.2 (3.9-9.3) | 14.2 (10.2-19.0)d | 58.7 (53.0-64.2) | 65.6 (59.8-71.1) |
| Hispanic | 49.9 (46.0-53.9)d | 9.3 (5.9-13.9)d | 13.9 (10.1-18.3)d | 70.9 (65.4-76.0)d | 79.9 (75.2-84.1)d |
| White, non-Hispanic [reference] | 80.3 (78.8-81.7) | 4.8 (4.0-5.7) | 7.9 (6.9-9.1) | 58.2 (56.2-60.1) | 64.6 (62.6-66.5) |
| Other, non-Hispanicf | 58.7 (53.0-64.2)d | 6.4 (3.4-11.0) | 5.7 (3.1-9.4) | 63.9 (56.9-70.4) | 75.7 (69.5-81.2)d |
| Educational level | |||||
| ≤High school diploma [reference] | 61.8 (59.1-64.4) | 6.8 (5.2-8.7) | 11.4 (9.5-13.6) | 58.1 (54.6-61.6) | 64.9 (61.6-68.2) |
| Some college | 75.7 (73.3-77.9)d | 5.6 (4.2-7.3) | 9.8 (8.1-11.9) | 59.9 (56.9-62.9) | 67.3 (64.3-70.1) |
| ≥Bachelor’s degree | 77.5 (75.5-79.4)d | 4.4 (3.4-5.6)d | 6.8 (5.6-8.2)d | 62.0 (59.5-64.5) | 69.3 (66.8-71.7)d |
| Urbanicity | |||||
| Metropolitan [reference] | 70.2 (68.7-71.7) | 5.6 (4.7-6.6) | 9.3 (8.3-10.5) | 60.9 (59.1-62.8) | 68.0 (66.2-69.7) |
| Nonmetropolitan | 76.2 (72.6-79.5)d | 5.4 (3.7-7.6) | 8.3 (5.9-11.3) | 55.3 (50.9-59.7)d | 63.4 (59.0-67.6)d |
| Region | |||||
| Northeast [reference] | 75.8 (72.5-78.9) | 6.4 (4.6-8.6) | 8.6 (6.7-10.8) | 61.7 (57.5-65.8) | 65.8 (61.9-69.6) |
| Midwest | 78.8 (76.2-81.2) | 4.8 (3.5-6.5) | 8.1 (6.3-10.2) | 59.4 (55.9-62.8) | 63.7 (60.4-67.0) |
| South | 66.2 (63.7-68.6)d | 4.8 (3.6-6.3) | 10.0 (8.3-12.0) | 58.9 (56.1-61.6) | 68.8 (65.9-71.5) |
| West | 68.5 (65.6-71.3)d | 6.7 (4.8-9.0) | 9.4 (7.4-11.8) | 61.5 (58.0-64.9) | 69.8 (66.3-73.2) |
| Household income | |||||
| <200% FPL [reference] | 60.5 (57.7-63.4) | 7.7 (5.9-9.7) | 12.3 (10.0-14.9) | 60.3 (56.6-63.8) | 68.9 (65.4-72.1) |
| ≥200 to <400% FPL | 72.1 (69.3-74.7)d | 5.3 (3.8-7.2) | 10.4 (8.6-12.4) | 61.0 (57.7-64.3) | 69.4 (66.1-72.5) |
| ≥400% FPL | 77.8 (75.9-79.6)d | 4.5 (3.5-5.7)d | 6.9 (5.7-8.3)d | 59.5 (57.1-61.9) | 65.3 (62.8-67.7)d |
Abbreviation: FPL, federal poverty level.
Data from the National Center for Health Statistics Rapid Surveys System.5 Missing responses, including those coded as “refused” or “don’t know,” were excluded from the respective analyses. Additional information on the data collection and survey weighting is available in the survey description.
This question was asked only among respondents who answered yes to the question, “Have you ever heard of the medication naloxone, also known as Narcan, which can be used to reverse an opioid overdose?”
These questions were asked only among respondents who answered no to the question, “Do you currently carry naloxone or Narcan?”
Difference from the reference group was significant based on 2-sided P < .05. Statistical significance was determined based on coefficients from an unadjusted logistic regression model of each demographic variable.
Self-reported by participants. Missing data for race and ethnicity were imputed.
Includes American Indian or Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, and multiple races.
Among adults who agreed that persons were to blame for their drug use, 4.3% currently carried naloxone compared with 8.3% among those who disagreed (Table 2). Awareness of where naloxone is available was highest for pharmacies (63.8%) and lowest for community harm-reduction organizations (31.7%). Agreement on where naloxone should be available was highest for college or university campuses (83.7%) and lowest for places of worship (54.0%). Both awareness of naloxone availability and agreement on where naloxone should be available were significantly lower among those who agreed persons were to blame for their drug use.
Table 2. Awareness of Naloxone Availability and Attitudes About Expanding Access Stratified by Agreement That Persons Are to Blame for Their Drug Usea.
| Adults, weighted % (95% CI) | P value for difference between agree and disagree categoriesd | |||
|---|---|---|---|---|
| Overall (unweighted N = 5258) | Among adults who agree that persons are to blame for their drug use (unweighted n = 3409)b | Among adults who disagree that persons are to blame for their drug use (unweighted n = 1781)c | ||
| Currently carry naloxone/Narcane | 5.6 (4.8-6.4) | 4.3 (3.4-5.3) | 8.3 (6.7-10.0) | <.001 |
| Are aware that naloxone is available at the following locationse | ||||
| Pharmacies | 63.8 (62.2-65.4) | 62.0 (60.0-64.0) | 68.0 (65.3-70.7) | <.001 |
| Over the counter without prescription | 52.4 (50.7-54.0) | 49.7 (47.7-51.7) | 58.3 (55.4-61.1) | <.001 |
| Physician offices | 47.0 (45.3-48.6) | 45.8 (43.7-47.9) | 49.3 (46.5-52.1) | .05 |
| Health departments | 43.0 (41.2-44.7) | 40.6 (38.6-42.7) | 48.2 (45.2-51.2) | <.001 |
| Community harm-reduction organizations | 31.7 (30.1-33.2) | 26.3 (24.5-28.1) | 42.6 (39.8-45.5) | <.001 |
| Agree that naloxone/Narcan should be available at the following locationse | ||||
| College or university campuses | 83.7 (82.4-84.9) | 78.9 (77.1-80.5) | 92.9 (91.1-94.3) | <.001 |
| High schools | 78.1 (76.7-79.5) | 72.8 (70.9-74.7) | 88.0 (86.0-89.9) | <.001 |
| Public libraries | 59.1 (57.5-60.8) | 51.4 (49.3-53.4) | 74.0 (71.4-76.5) | <.001 |
| Elementary and middle schools | 56.5 (54.8-58.1) | 51.2 (49.2-53.3) | 66.3 (63.4-69.1) | <.001 |
| Businesses | 55.5 (53.8-57.1) | 49.1 (47.1-51.1) | 67.4 (64.7-70.0) | <.001 |
| Places of worship | 54.0 (52.4-55.7) | 46.0 (43.9-48.1) | 69.1 (66.4-71.7) | <.001 |
Data from the National Center for Health Statistics Rapid Surveys System.5 Missing responses including those coded as “refused” or “don’t know” were excluded from the respective analyses. Additional information on the data collection and survey weighting is available in the survey description.
Based on a response of “strongly agree” or “somewhat agree” to the question, “How much do you agree or disagree with the following statement? I think that a person who misuses prescription opioids or uses illegal drugs, such as cocaine or heroin, is to blame for his or her drug use.”
Based on a response of “strongly disagree” or “somewhat disagree” to the question, “How much do you agree or disagree with the following statement? I think that a person who misuses prescription opioids or uses illegal drugs, such as cocaine or heroin, is to blame for his or her drug use.”
Two-sided P values were calculated using Rao-Scott χ2.
These questions were asked only among respondents who answered yes to the question, “Have you ever heard of the medication naloxone, also known as Narcan, which can be used to reverse an opioid overdose?”
Discussion
This study found that, although most adults reported having heard of naloxone, few carried naloxone. Those reporting highest awareness of naloxone also reported lowest prevalence of carrying naloxone, potentially indicating that different factors affect these outcomes. Younger adults, females, Hispanic adults, and those residing in metropolitan areas had a higher prevalence of not knowing how to use or where to get naloxone; non-Hispanic Black and Hispanic adults had higher prevalence of thinking naloxone does not work. Blaming persons for their drug use was associated with lower prevalence of carrying naloxone and having awareness of and agreement with naloxone availability in various locations. Overall, naloxone awareness and agreement with additional access were high, but barriers were reported, such as not knowing how to use or where to get naloxone. Public health initiatives that increase naloxone access and training could help save lives from overdose.
Study limitations include generalizability only to noninstitutionalized civilian adults, potential recall bias, and lower response rates, which may contribute to nonresponse bias. Despite these limitations, this study identified opportunities to expand naloxone access and education and highlighted the importance of addressing stigma surrounding persons who use drugs.
Data Sharing Statement
References
- 1.US Food and Drug Administration. Information about naloxone and nalmefene. Accessed December 11, 2024. https://www.fda.gov/drugs/postmarket-drug-safety-information-patients-and-providers/information-about-naloxone-and-nalmefene
- 2.Rikard SM, Strahan AE, Schieber LZ, Guy GP Jr. Trends in naloxone dispensing from retail pharmacies in the US. JAMA. 2024;332(2):165-167. doi: 10.1001/jama.2024.8323 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Irvine MA, Oller D, Boggis J, et al. Estimating naloxone need in the USA across fentanyl, heroin, and prescription opioid epidemics: a modelling study. Lancet Public Health. 2022;7(3):e210-e218. doi: 10.1016/S2468-2667(21)00304-2 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 4.Bessen S, Metcalf SA, Saunders EC, et al. Barriers to naloxone use and acceptance among opioid users, first responders, and emergency department providers in New Hampshire, USA. Int J Drug Policy. 2019;74:144-151. doi: 10.1016/j.drugpo.2019.09.008 [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.National Center for Health Statistics . Survey description—Round 2: data collected October-November 2023. NCHS Rapid Surveys System. Accessed July 1, 2024. https://www.cdc.gov/nchs/data/rss/round2/survey-description.pdf
Associated Data
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Supplementary Materials
Data Sharing Statement