Perspectives of opioid users on overdose recognition, naloxone administration, and attitudes

Abstract

Background:

There has been a rise in opioid overdose deaths, despite harm reduction efforts like naloxone distribution. Naloxone is effective but underused due to knowledge gaps and stigma.

Aim:

To assess opioid users’ knowledge regarding overdose and attitudes, experiences toward naloxone.

Materials and Methods:

This cross-sectional study was conducted from August 2024 to May 2025 at a Deaddiction center. Participants with opioid use disorder were interviewed using a semistructured performa and the Brief Opioid Overdose Knowledge questionnaire to assess opioid users’ knowledge and attitudes toward naloxone.

Results:

Our study involved 501 participants, mostly males (mean age = 27.16 years) with substance use averaging 6.5 years. Nearly half had overdose history, with serious outcomes common. Knowledge, overdose recognition, and overdose response scores varied significantly based on factors like history of overdose, awareness and use of naloxone, education, and socioeconomic status. Knowledge about naloxone was low, with mixed attitudes and significant barriers like stigma and poor access.

Conclusion:

Our study reveals that despite naloxone’s proven efficacy in reversing opioid overdoses, its use is limited by stigma, poor awareness, and restricted access. Enhancing harm reduction education and destigmatization through tailored community interventions is vital to preventing overdose fatalities.

The global opioid crisis has emerged as a significant public health challenge, leading to rising morbidity and mortality rates due to opioid overdose.[1] Overdose deaths, primarily driven by opioids, continue to escalate, necessitating urgent interventions to mitigate their impact.

Numerous strategies have been implemented to respond to the growth in opioid overdose deaths—educating health care providers and the public, prescription monitoring programs, prescription drug take-back programs, and overdose prevention education and naloxone distribution programs.[2] One of the most effective harm reduction strategies for opioid overdose is the administration of naloxone, an opioid antagonist that rapidly reverses the effects of opioid toxicity.[3] Evaluations from several pilot studies have shown that drug-using peers are capable of effectively administrating naloxone and saving lives.[4,5,6] Naloxone has been widely recognized as a life-saving intervention, and its accessibility has expanded through community distribution programs, pharmacy initiatives, and legislation promoting take-home naloxone kits.[7] Despite these advancements, knowledge gaps regarding opioid overdose recognition and naloxone administration persist among opioid users, who are often the first witnesses to an overdose event.

Today, there are hundreds of programs distributing naloxone in over 10 countries around the world.[8,9] Assessing their awareness of overdose signs, risk factors, and appropriate responses can help identify barriers to naloxone use and inform strategies to improve accessibility and acceptance. Additionally, addressing misconceptions and stigma associated with naloxone can enhance its utilization and ultimately reduce opioid-related fatalities.

This study aimed to assess the knowledge of opioid overdose, naloxone, attitude toward naloxone, and experiences associated with it among opioid users. The drug deaddiction center of our institute is a tertiary care center that mostly fulfills the needs of the Kashmir valley, and the findings of our study will provide valuable insights for harm reduction initiatives, healthcare providers, and policymakers seeking to improve opioid overdose prevention efforts.

MATERIALS AND METHODS

This was a cross-sectional study conducted at the deaddiction OPD of a tertiary care hospital in Kashmir, from August 2024 to May 2025. Participants were recruited using a nonprobability convenience sampling technique after getting written informed consent. We did not calculate the sample size before conducting the study, which is one of the limitations of our study.

Study population

The inclusion criteria were: (a) patients aged ≥18 years; (b) meeting criteria for opioid use disorder (as per Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition[10]), and (c) providing written informed consent. The exclusion criterion was patients who refused to provide written informed consent.

Individual interview sessions were conducted by psychiatrists, and the data were collected accordingly. Basic sociodemographic data and substance history were collected using a semistructured performa. Another semistructured performa was made with the consultation of experienced and senior psychiatrists, experts in the addiction field, and who are also co-authors of this research study, for assessing knowledge, attitude, experiences, and barriers toward naloxone. The complete set of this questionnaire has been attached in the supplementary file section. For data like overdose history, naloxone use, other attitude and knowledge questions, we conducted private interviewer-administered sessions by trained psychiatrists (who are co-authors), assurance of confidentiality and that responses would not influence treatment, and we cross-checked available clinical records (e.g., documented overdoses, comorbidity status) where possible.

For opioid overdose knowledge and response, we utilized the Brief Opioid Overdose Knowledge questionnaire (BOOK), developed by Dunn KE et al.[11] BOOK is a 12-item questionnaire comprising three subdomains, general opioid knowledge, opioid overdose knowledge, and opioid overdose response knowledge subscale, and the combined score is the BOOK total.[11] Individuals are asked to mark either True, False, or I don’t know for each question, and the scores are added across each subscale. Factor analysis was done and this scale has well accepted reliability and acceptability, with alpha (discrimination) [factor loading] values of category 1 (general opioid knowledge) ranging from 0.4 to 1.3 [0.3 to 0.8], category 2 (opioid overdose risk knowledge) ranging from 0.2 to 1.4 [0.2 to 0.8], category 3 (opioid overdose response knowledge) ranging from 0.6 to 1.5 [0.5 to 0.8].[11]

All data analysis was carried out in Statistical Package of Social Sciences (SPSS) version 25.0 (IBM Corp.). The continuous variables were expressed as mean and standard deviation, ordinal variables as median and interquartile range (IQR), and the categorical variables were expressed as frequency and percentages. Mann-Whitney U-test was used to test the difference between two variables, and Kruskal-Wallis test was used to assess between multiple variables. P values <0.05 were considered statistically significant in our study.

RESULTS

A total of 501 participants were recruited in our study. Mean age (+ SD) of the study sample was 27.16 ± 6.14 years. Mean (+ SD) of duration of substance use was 6.53 ± 4.12 years. The sociodemographic details of our participants are mentioned in Table 1. The score of BOOK across different variables is presented in Table 2. The details regarding naloxone use among our participants are presented in Table 3. The details regarding attitude toward naloxone among our participants are presented in Table 4. The details regarding experience with naloxone use are mentioned in Table 5.

Table 1.

Demographic profile of the enrolled population

Variables		Frequency	Percentage (%)
Gender	Male	500	99.8
	Female	1	0.2
Education	Primary	50	10.0
	Secondary	193	38.5
	Senior secondary	151	30.1
	Graduate	99	19.8
	Postgraduate	8	1.6
Marital status	Unmarried	346	69.1
	Married	155	30.9
Socioeconomic status	Upper	19	3.8
	Upper middle	14	2.8
	Lower middle	465	92.8
	Upper lower	0	0
	Lower	3	.6
Comorbidity	Negative	156	31.1
	Hepatitis C	265	52.9
	Hepatitis B	40	8.0
	HIV	13	2.6
	Test not done	27	5.3
Family members knowledge	Yes	56	11.2
	No	445	88.8
Overdose Present		249	49.7
Act in overdose	Hospitalization	42	16.87
	Breathlessness	3	1.2
	Admitted in ICU	12	4.82
	RTA	3	1.2
	Seizure	4	1.61
	Self-harm	5	2.0
	Stroke	1	0.4
	Tachycardia	4	1.61
	Unconsciousness	168	67.47
	Vomiting	7	2.81
Has seen any death due to overdose	Yes	169	33.7
	No	332	66.3

Table 2.

BOOK score across demographic and clinical variables

Variable	Subgroup	General Knowledge	Overdose Knowledge	Overdose Response	BOOK Total
		Median (IQR)
History of overdose	Yes	2 (2−3)	4 (4−4)	2 (1−3)	8 (7−9)
	No	2 (1−2)	4 (4−4)	3 (2−3)	8 (7−9)
	P	<0.001	0.08	0.47	0.25
Seen a death	Yes	2 (2−3)	4 (3−4)	2 (1−3)	8 (6−10)
	No	2 (1−2)	4 (4−4)	3 (2−3)	8 (7−9)
	P	<0.001	<0.001	0.05	0.43
Heard of naloxone	Yes	4 (2−4)	4 (4−4)	4 (3−4)	11 (9−12)
	No	2 (1−2)	4 (4−4)	2 (1−3)	8 (7−8.5)
	P	<0.001	0.21	<0.001	<0.001
Used naloxone	Yes	4 (2−4)	4 (4−4)	4 (4−4)	12 (9−12)
	No	3 (3−4)	4 (3−4)	4 (3−4)	9 (9−11)
	P	0.14	<0.001	0.02	<0.001
Education	Primary	2 (1−3)	4 (4−4)	3 (1.75−3)	8 (7−9)
	Secondary	2 (1−3)	4 (4−4)	3 (2−3)	8 (7−9)
	Senior Secondary	2 (1−2)	4 (4−4)	3 (1−3)	8 (7−9)
	Graduate	2 (1−2)	4 (4−4)	2 (1−3)	8 (6−9)
	Postgraduate	3.5 (2−4)	3.5 (2.25−4)	2.5 (2−3.75)	8 (7−11)
	P	0.08	0.05	0.26	0.45
Socioeconomic status	Upper	3 (1−4)	4	3 (1−4)	9 (7−12)
	Upper Middle	2	4	3 (1.75−3.25)	8 (8−9.5)
	Lower Middle	2	4	3 (2−3)	8 (7−9)
	Lower	2	3	0	7 (3−7)
	P	0.33	0.02	0.22	0.16

Table 3.

Knowledge regarding naloxone

Variable		Frequency	Percentage
Have you heard and know about Naloxone?	Yes	100	20.0
Source	Health care professional	87	87.0
	Pharmacy	12	12.0
	Friends	1	1.0
Knowledge about the reversal of opioid overdose by naloxone	Strongly disagree	0	0
	Disagree	1	1.0
	Neutral	17	17.0
	Agree	25	25.0
	Strongly agree	57	57.0
Knowledge of withdrawal opioid symptoms with the use of naloxone	Yes	84	84.0
	No	16	16.0
How many withdrawals have you heard of after receiving naloxone?	None	17	17.0
	Mild	16	16.0
	Moderate	42	42.0
	Severe	25	25.0

Table 4.

Attitude toward naloxone use (n=100)

Variables		Frequency	Percentage
Do you think it should be compulsory taken by everyone who is prescribed prescription opioids (e.g., buprenorphine)	Strongly disagree	10	10.0
	Disagree	16	16.0
	Neutral	32	32.0
	Agree	4	4.0
	Strongly agree	38	38.0
Do you think it should be made readily available as an over-the-counter medication?	Strongly disagree	0	0
	Disagree	0	0
	Neutral	16	16.0
	Agree	7	7.0
	Strongly agree	77	77.0
Do you think individuals will start engaging in riskier opioid use if it becomes readily available?	Strongly disagree	16	16.0
	Disagree	21	21.0
	Neutral	57	57.0
	Agree	0	0
	Strongly agree	6	6.0
Do you think people will judge you for using naloxone?	Very Often	19	19.0
	Often	2	2.0
	Some times	77	77.0
	Rarely	0	0
	Never	2	2.0
Do you think healthcare providers will judge you for using naloxone?	Very Often	4	4.0
	Often	1	1.0
	Sometimes	66	66.0
	Rarely	27	27.0
	Never	2	2.0
Do you think people will consider you an opioid users if you use or carry naloxone?	Strongly disagree	0	0
	Disagree	3	3.0
	Neutral	65	65.0
	Agree	10	10.0
	Strongly agree	22	22.0
Do you feel comfortable discussing naloxone use with people?	Very Often	1	1.0
	Often	13	13.0
	Some times	75	75.0
	Rarely	10	10.0
	Never	1	1.0
Have you heard of criticism from people if you used or carried naloxone?	Very Often	8	1.6
	Often	1	.2
	Some times	67	13.4
	Rarely	10	2.0
	Never	14	2.8
What did you experience in criticism from people?	Verbal criticism	35	35.0
	Negative judgement	63	63.0
	Social exclusion	0	0
	Legal consequences	0	0
	Others	2	2.0

Table 5.

Experience with naloxone use

Variables		Frequency	Percentage
Have you used naloxone	Yes	73	73.0
	No	27	27.0
How many times have you used naloxone?	2−5 times	73	100.0
Route (n=73)	Intravenous (IV)	73	73.0
	Intramuscular (IM)	0	0
	Intra nasal	0	0
	Subcutaneous (SC)	0	0
Has someone you know used naloxone? (n=73)	Yes	69	94.5
	No	4	5.5
What was the response to naloxone use (n=69)	No Response	0	0
	Partial reversal	0	0
	Complete reversal	69	69.0
How many withdrawals have you seen or experienced (n=69)	Mild	1	1.45
	Moderate	17	24.64
	Severe	51	73.91

Barriers to naloxone use

Among the 100 participants who had heard about naloxone, all of them (100.0%) reported facing barriers in accessing naloxone. The most commonly reported barriers were lack of knowledge (80.0%) and stigma associated with its use (70.0%). Additionally, 26 participants reported a lack of availability as a barrier, while 17 participants cited a lack of logistics.

DISCUSSION

The aim of this study was to assess opioid users’ awareness of overdose symptoms and their knowledge and attitudes toward naloxone—a critical life-saving intervention in opioid overdose situations. In our study, participants who had heard of naloxone demonstrated markedly higher knowledge scores compared to those who had not. This substantial difference highlights the strong association between awareness of naloxone and greater understanding of opioid overdose. Naloxone, an opioid antagonist used in reversing opioid overdose, is important in overdose education and harm reduction programs. Individuals aware of naloxone are more likely to have engaged in harm reduction initiatives, which typically include training on overdose identification and intervention, thus increasing their knowledge scores. This could indicate that naloxone awareness serves as a proxy indicator of higher overall competence in opioid overdose prevention. Encouraging broader access to naloxone not only prevents overdose deaths but also empowers individuals through experiential learning, reinforcing both confidence and capability in overdose situations.[12]

We found limited awareness of naloxone among our study population, with only 20% (N = 100) reporting that they had heard about naloxone. This reflects a significant gap in harm reduction awareness, particularly given the high prevalence of opioid use and overdose observed in our population. Healthcare providers who are prescribing them medications should make them aware regarding naloxone and its benefit in critical situations. Among those aware of naloxone, healthcare professionals were the predominant source of information. This suggests that formal medical settings remain the primary source of naloxone education. Expanding community-based training and integrating overdose education into routine care settings could bridge this gap. Regarding the effectiveness of naloxone in reversing opioid overdose, 57% strongly agreed and 25% agreed, expressing confidence in its life-saving capacity. However, there was more uncertainty around the withdrawal symptoms associated with naloxone use. While 84% reported awareness that naloxone can precipitate withdrawal symptoms, knowledge about severity varied. Forty two percent reported moderate withdrawal, 25% severe, and 17% reported none, indicating some ambiguity or inconsistent experiences with naloxone-induced withdrawal. Our finding highlights a critical need for expanding naloxone education among opioid users. While those exposed to medical systems tend to have high trust in naloxone’s efficacy, awareness remains limited in the broader community. Furthermore, knowledge about withdrawal symptoms varies, indicating a need for more comprehensive and context-sensitive training programs. Greater involvement of community pharmacies, peer educators, and harm reduction organizations could significantly enhance public understanding and acceptance of naloxone.

Regarding attitude toward naloxone, our findings highlights need for public health interventions, naloxone distribution and in shaping positive perception and reducing stigma. Regarding whether naloxone should be made compulsory for those prescribed opioids such as buprenorphine, only 42% (Agree + Strongly Agree) supported this idea, while 26% (Strongly Disagree + Disagree) opposed it, and 32% remained neutral. This reflects a lack of awareness or trust in preventive strategies. In contrast, there was overwhelming agreement for making naloxone available over the counter, with no respondents disagreeing. Despite positive views on access, stigma remained a significant barrier. Majority believed they would be judged by others, and felt healthcare providers might sometimes judge them for using or carrying naloxone. Additionally, they have experienced criticism when they have carried naloxone. This concern was also raised in previous study, who reported that stigma about naloxone usage, even when they recognized its life-saving potential.[12] The psychological burden of verbal or social judgment may deter some individuals from using or accessing naloxone. While naloxone is viewed positively in terms of accessibility and efficacy, social and institutional stigma continues to shape users’ willingness to engage with it. Efforts to normalize naloxone possession, particularly through community outreach, peer support, and antistigma campaigns, are crucial. Training healthcare providers in nonjudgmental communication can further reduce perceived discrimination and promote harm reduction.

As per our study, the majority (73%) of participants reported having personally used naloxone via the intravenous route, demonstrating a relatively high level of hands-on engagement with the medication. Among those who had used naloxone (N = 73), 100% reported using it 2–5 times, indicating repeated exposure and suggesting that the population may have had regular encounters with opioid overdose events—either personally or as bystanders. This is consistent with the context of India and other low-resource settings, where IV administration remains common due to healthcare norms and availability of injectable naloxone through hospital-based systems or informal channels. Moreover, every individual reported complete reversal of overdose symptoms following naloxone administration, indicating high perceived efficacy and consistent with naloxone’s pharmacological profile as an opioid antagonist. However, opioid withdrawal symptoms following naloxone use were significant. Among those who either experienced or witnessed naloxone use, the majority reported severe withdrawal symptoms. It emphasizes the need for counseling and education about what to expect postadministration, and the importance of combining naloxone distribution with information on withdrawal management.

All of our participants reported facing at least one barrier in accessing or using naloxone. A universal barrier cited was the lack of adequate knowledge regarding naloxone. This reflects a gap in health education and awareness, even among those who had previously used or heard of naloxone. Despite the life-saving potential of the drug, many individuals may not receive formal training or information about its administration, dosage, or indications. Previous study have similarly emphasized that limited public education and inadequate training for laypersons reduce the efficacy and confidence in naloxone use.[13] Other majority had stigma associated with naloxone use. This stigma often stems from societal perceptions that carrying or using naloxone formulates to being a drug user. Research has shown that stigma remains a major barrier to carrying or administering naloxone due to fear of social judgment, discrimination, or being labeled as an opioid user.[14] Such stigmatization can deter individuals, particularly those on prescription opioids or caregivers, from carrying or taking naloxone, despite their potential need. Another concern raised by participants was the lack of availability of naloxone, which was reflective of Kashmir setting. In our union territory and many such peripheral regions, naloxone is not widely available over the counter and often requires a prescription or institutional access. Logistic concerns may also affect individuals in remote areas or those with limited mobility or financial resources. The findings highlight that while naloxone is recognized as a critical tool in reversing opioid overdose, barriers to its use remain deeply embedded in systemic, educational, and social structures.

We found similar median or statistically insignificant findings in BOOK total and its subdomains general knowledge, opioid overdose and overdose response with overdose history, visualization of death due to overdose, naloxone utilization, and educational status, and cannot infer from it. Future studies should be performed to explore the association of BOOK with these variables in detail.

Limitations

First, it was a cross-sectional study, and causal relationships between knowledge, attitudes, and naloxone use behaviors cannot be studied. Second, our sample was drawn from a specific geographic region (Kashmir) and may not be representative of all opioid users in India, limiting generalizability. Third, self-reported data on overdose experiences and naloxone use could be affected by bias, particularly regarding stigmatized behaviors. Fourth, while we studied knowledge and attitudes, we did not evaluate actual overdose response behaviors in real-time, which may differ from reported preparedness. Fifth, the use of consecutive non-probability sampling may limit external validity. Sixth, we used a custom questionnaire to assess attitudes and experiences. We did not calculate the sample size before conducting the study. Last, the study included only individuals who were already accessing some form of care or services, potentially excluding those most marginalized or disconnected from healthcare systems, who may have different levels of awareness and access to naloxone.

CONCLUSION

Our study highlights the need to improve awareness, accessibility, and attitudes toward naloxone among opioid users. Despite high overdose rates and demonstrated efficacy of naloxone, its use is affected by stigma, lack of knowledge, and limited availability. Greater emphasis on harm reduction education and destigmatization strategies is essential. Community-based interventions are needed to reduce preventable overdose deaths.

Authors’ contributions

Concept, design, literature search: RR, SP, SMW. Data acquisition: SP. Data analysis: IH, RR Manuscript preparation: RR, SP. Manuscript editing and manuscript review: ZAW, YHR.

Ethical statement

The Institutional Review Board of Government Medical College, Srinagar (IRBGMC-SGR/Psy/616; dated 27/07/2024), approved the study protocol, ensuring adherence to ethical guidelines.

Consent to participate

Written Informed consent was taken from all participants.

Conflicts of interest

There are no conflicts of interest.

Data availability

Data can be made available on reasonable request.

SUPPLEMENTARY FILE

KNOWLEDGE REGARDING NALOXONE:

Have you heard and know of naloxone? Yes / No

If yes, source: friends / family / healthcare staff / media / pharmacy / community outreach campaigns

How much do you know about naloxone:

none / somewhat / completely

Can naloxone reverse opioid overdose? :

Strongly disagree / disagree / neutral / agree / strongly agree

Do you know, it causes withdrawal symptoms?

Yes / No

If yes, How much withdrawal you have heard of, after receiving naloxone?

None / Mild / moderate / severe

ATTITUDE TOWARDS NALOXONE USE:

Do you think it should be compulsory taken by everyone who are prescribed prescription opioids (e.g. buprenorphine) :

Strongly disagree / disagree / neutral / agree / strongly agree

Do you think, it should be made readily available as over the counter medication? Strongly disagree / disagree / neutral / agree / strongly agree

Do you think, individuals will start engaging in riskier opioid use if naloxone becomes readily available?

Strongly disagree / disagree / neutral / agree / strongly agree

Do you think, people will judge you for using naloxone?

Very often / Often / Sometimes / Rarely / Never

Do you think, healthcare providers will judge you for using naloxone?

Very often / Often / Sometimes / Rarely / Never

Do you think, people will consider you as opioid user if you use or carry naloxone?

Strongly disagree / disagree / neutral / agree / strongly agree

Do you feel comfortable discussing naloxone use with people?

Very often / Often / Sometimes / Rarely / Never

Have you heard of criticism from people, if you used or carried naloxone?

Very often / Often / Sometimes / Rarely / Never

If yes, what did you experienced?

Verbal criticism / negative judgement / social exclusion / legal consequences

If others, please specify:

EXPERIENCES WITH NALOXONE USE:

Have you used naloxone ever? Yes / no

If yes, how many times?

Once / 2 - 5 times / more than 5 times

If yes, route: (can select multiple)

Iv / im/ sc / intranasal

Has someone you know has used naloxone?: Yes / No

If yes, What was the response on naloxone use? :

no response / partial reversal of overdose / complete reversal of overdose

if yes, How much withdrawal you have seen or experienced after receiving naloxone?

None / Mild / moderate / severe

BARRIER TO NALOXONE USE:

Have you faced any barrier in accessing naloxone? Yes / No

If yes, what were the barriers? (can select multiple)

• - Lack of knowledge where to get it

• - Lack of logistics

• - Stigma association

• - Lack of availability

• - Lack of affordability

Funding Statement

Nil.