‘I have it just in case’ — Naloxone access and changes in opioid use behaviours

Abstract

Background:

The past decade has seen over a four-fold increase in deaths from opioid overdose in the United States. To address this growing epidemic, many localities initiated policies to expand access to naloxone (a drug that reverses the effects of opioids); however, little is known how naloxone access affects opioid use behaviours.

Methods:

The present qualitative study used semi-structured, in-depth interviews with inpatients at a substance use treatment centre. All patients who met study inclusion criteria (in treatment for opioid use, between the ages of 18 and 40, able to speak and understand English, and had not previously completed an interview with the research team) were invited to participate. Interviews were conducted until thematic saturation was reached (N = 20) and covered the participant’s naloxone knowledge, access, and attitudes, as well as experience(s) with opioid use and opioid overdose, and their naloxone use in the context of opioid overdose. Thematic content analysis was used to analyze interview transcripts.

Results:

Five main themes were uncovered during analysis; first, awareness about naloxone, including, content knowledge and source information for naloxone. Naloxone awareness was very common among opioid users; however, depth of knowledge varied; some participants did not make any efforts to have naloxone available, and others felt that it was “just as important as a clean needle.” The second theme explored how naloxone access intersects with drug selling. The third theme explored naloxone availability while using, including attitudes about naloxone, occasions with no naloxone availability, when naloxone is “good to have,” and when naloxone is a priority for users. The fourth theme examined changes in opioid use behaviours associated with naloxone access. Primarily, participants discussed changing how much heroin they used in a given situation to achieve a bigger high. The final theme explored naloxone behaviours that alter overdose mortality risk, such as how users distinguish when to use naloxone, dis-incentives to naloxone use, and solo opioid use.

Conclusion:

Results indicate that though naloxone awareness was high, there was great variation in the associated attitudes and practices. Participants generally described naloxone as an important resource, but not all were inclined to carry or use it appropriately. Future research needs to examine why different groups of opioid users access naloxone differently, particularly to identify those at risk for experimental opioid use while carrying naloxone.

Opioid overdose death continues to be a critical public health crisis in the United States (U.S.). In 2015 there were 33,091 deaths from opioid overdose, an increase of 15.5% from the previous year (Rudd, Seth, David, & Scholl, 2016). This trend has been increasing dramatically over the last several years; there has been a 220% increase in opioid overdose deaths since 2002 (Rudd et al., 2016). Further, these deaths are being driven by synthetic opioids like fentanyl, in addition to heroin. From 2014 to 2015, there was a 72.2% increase in deaths from synthetic opioids other than methadone (e.g., fentanyl) and a 20.6% increase in deaths from heroin; these trends applied across all demographic groups and U.S. regions (Rudd et al., 2016).

Also of note is the global nature of opioid use and overdose; some estimates indicate that up to 39 million individuals are “problem users of opioids” (Degenhardt & Hall, 2012: p. 55). Opioid dependence accounts for 9.2 million disability-adjusted life years (SALYs), an increase of 73% from 1990 to 2010 (Degenhardt et al., 2014). A recent systematic review indicates that global lifetime prevalence for drug users experiencing a non-fatal overdose range from 16.6% to 68.0% of users; further, the population-based overdose mortality rate ranged from 0.04 to 46.6 per 100,000 person-years (Martins, Sampson, Cerda, & Galea, 2015). Diversity in region, time periods, and samples likely accounts for the wide ranges for these estimates (Martins et al., 2015). Importantly, these estimates likely under-estimate the global burden of disease associated with opioid use and overdose as rates have increased steadily between 2010 and 2015 in the United States (Rudd et al., 2016).

The increase in nonmedical opioid use has been aided by opioid prescriptions written by medical providers for specific pain conditions (Compton & Volkow, 2006; Kolodny et al., 2015). In 2012, providers wrote enough opioid medication prescriptions for each adult in the United States to receive one bottle of opioid pain pills (Centers for Disease Control and Prevention, 2014). The increased frequency and high dosing of prescription pain pills has led to opioid addiction and individuals who use opioid medications purely for the feeling they cause (Compton & Volkow, 2006; Kolodny et al., 2015). Other research has shown that prescription opioids are perceived as less dangerous than heroin among nonmedical opioid users because prescription opioids are prescribed by a physician (Daniulaityte, Falck, & Carlson, 2012). Further, pharmaceutical companies that manufacture opioids exploited the effort to treat pain as a “fifth vital sign” and supplemented doctors’ prescribing habits with aggressive marketing; Purdue Pharma even went so far as to promote their controlled-release OxyContin as safe for chronic pain and non-addictive (Meldrum, 2016; Van Zee, 2009). As a result, more Americans became addicted to prescription opioids. Many individuals began switching to heroin once opioid pills became more challenging to obtain or did not provide an adequate high (Jones, 2013; Mars, Bourgois, Karandinos, Montero, & Ciccarone, 2014). The rate of heroin use has risen dramatically, as has the rate of heroin overdose (Kolodny et al., 2015; Rudd et al., 2016).

To address this growing epidemic, states initiated policies to expand naloxone (Narcan^® ADAPT Pharma) access. Naloxone is an opioid antagonist that reverses opioid overdose; it is safe, effective, and can be administered using a syringe (intramuscularly) or intranasal atomizer (intranasally) (Boyer, 2012). Naloxone administration is time-sensitive, that is, the sooner it is administered after an overdose, the more likely it is to effectively reverse the overdose. As a result, opioid overdose prevention initiatives have targeted naloxone education and distribution programs at non-medical personnel (“lay people”), such as friends, family members, and opioid users (e.g., Wagner et al., 2010). These individuals are often the ‘best’ responders because they are at the scene of an overdose first (World Health Organization, 2014). Currently, 43 US states and the District of Columbia have expanded naloxone access to lay people (Davis & Carr, 2015), with states implementing these policies as early as 2007 (Hawk, Vaca, & D’Onofrio, 2015).

Expanded naloxone access usually occurs through opioid education and naloxone distribution (OEND) programs. OEND programs generally review signs and symptoms of overdose, how to administer naloxone, and provide each participant with a naloxone rescue kit. Naloxone rescue kits typically include two naloxone doses, a naloxone administration device (either an intranasal atomizer or syringe), gloves, and an instruction card that reviews naloxone administration procedures. Some programs target opioid users, such as those within needle exchanges, while others are open to all community members (Mueller, Walley, Calcaterra, Glanz, & Binswanger, 2015). Research indicates these are successful at increasing participants’ knowledge and ability to respond to an overdose with naloxone (Mueller et al., 2015). Further, drug users, as well as lay people, are willing to be trained and respond to an opioid overdose with naloxone (Mueller et al., 2015). However, there was also concern in a general population sample that expanding naloxone access would result in more reckless use and reduce an individual’s desire to stop using opioids (Rudski, 2016). These concerns were similar to those expressed by medical providers, particularly whether naloxone would increase current drug use, allow for riskier drug use, or provide a false sense of security to drug users (Green et al., 2013).

Currently, we do not know if these concerns are valid. There is a serious gap in knowledge around how naloxone affects opioid use behaviours and its associated health and social consequences. Our previous research suggests that ‘concerned others,’ such as family members and friends of opioid users, are accessing the OEND, but it is not permeating to the drug users themselves (Heavey, Burstein, Moore, & Homish, 2017). Further, we are unaware of any research that has examined what effects naloxone has on opioid use behaviours.

Methods

The present research

The purpose of the present study is to examine naloxone access experiences among those in treatment for opioid use. As this is largely unexplored, we used in-depth interviews to develop a preliminary understanding awareness, access, attitudes, and behaviours about naloxone among those who use opioids. In the context of this study, awareness explores what participants know about naloxone and where they obtained that knowledge from; access explores whether participants have a naloxone kit and different routes for obtaining a kit; attitudes examines what participants feel about naloxone and opioid use; and behaviours explore how participants use (or do not use) a naloxone kit. We aimed to develop themes that will add to the broader theoretical understanding of overdose and naloxone use. These findings will add to knowledge in both the United States and internationally, particularly as opioid overdose is a global issue.

Study site

The present research took place at a residential substance use treatment centre. Researchers selected this centre in order to reach those with extensive opioid use experience, based on the rationale that those with extensive experience would be the optimum sample to develop preliminary understanding of overdose and naloxone use. This specific treatment centre has the widest catchment area in the region and serves 8 counties in the Western New York State region. Each patient receives specific treatment plans upon admission that routinely include physical health, mental health, and substance use counseling. Patients live at the centre for the duration of their treatment; typical treatment duration is 21 days.

Procedures

Researchers gave potential participants an overview of the study at the treatment centre’s weekly community meetings in which all patients attend and discuss issues related to the community as a whole (e.g., scheduling changes, room needs, etc.). This was the single opportunity during the week to reach all patients in a single setting. Researchers were available to talk individually with patients and answer questions. Patients could participate if they were currently receiving treatment for opioid use at the centre; were able to speak and understand English; were between the ages of 18 and 40 years; were willing and able to participate; and had not completed an interview with the research team previously. Once a patient was screened and determined eligible, s/he was scheduled for an interview. Participants were interviewed individually because of the sensitive nature of drug use and overdose. The semi-structured interviews were designed to provide qualitative data that included the participant’s naloxone awareness, access, attitudes, and behaviours, as well as experience (s) with opioid use and opioid overdose, and their naloxone use in the context of opioid overdose. These topics were outlined in an interview guide, which also included additional prompts or questions to elicit participant responses, as needed. All interviews were conducted by the first author and a trained research assistant who served as note-taker. The note-taker’s primary role was to capture broad themes as they were discussed (e.g., “the participant was aware of naloxone but never used it themselves”). Researchers used these notes to determine when thematic saturation was reached and therefore additional interviews were no longer needed. Prior to beginning the interview, the first author confirmed participant was comfortable with a note-taker present and were given the opportunity to decline the notetaker’s presence. Interviews took place in a private room at the treatment centre; prior to starting the interview, each participant was ensured of confidentiality and their rights as a research participant. At the conclusion of the interview, participants were asked if there was anything they wanted to add or if any other questions should have been asked, but were not.

All interviews were audio-recorded and transcribed verbatim to maintain data integrity. Interviews lasted approximately 40–60 min and were conducted in a private room after participants went through a consent process and gave verbal consent. In addition to the interview, participants completed a brief paper and pencil survey that gathered information on demographics, substance use, and overdose experiences. This form was dual-entered by research assistants using REDCap electronic data capture tools hosted at the University at Buffalo (Harris et al., 2009). At the conclusion of the interview, each participant received a $10 grocery store gift card as a thank you for their time. The full study protocol, including screening materials, demographics questionnaire, interview guide, and procedures, was screened, reviewed, and approved by the University at Buffalo’s Institutional Review Board.

Analysis

The analytic approach used thematic analysis, or identifying themes through iterative reading of the verbatim transcripts and took a hybrid approach (as in Marshall, Perreault, Archambault, & Milton, 2017, for example) and was thoroughly outlined in (Fereday & Muir-Cochrane, 2006). The thematic analysis began with a deductive approach based on Crabtree and Miller (1999). The codes used during this approach were defined a priori based on the research questions. The predefined codebook included code definitions and examples and was used as a guide the first author while conducting the deductive thematic analysis.

Second, to ensure important themes that emerged from the data were not overlooked, an inductive approach was used (Boyatzis, 1998). Codes were developed based on the frequency of concepts most often reflected in the participants’ statements. These codes were listed and clustered into categories based on overlap/similarity. Once a consensus was reached for coding, broad themes, and definitions, a repeated review of coding was conducted to integrate the deductive and inductive approach and ensure adequate interpretation of data by the research staff. All interviews were coded using Atlas.ti software (Development SS, 1999). Demographic characteristics, substance use, and overdose experiences were examined using Stata 14 (Corp, 2015).

Results

Participants

Participants (N = 20; 12 male, 8 female) reported an average age of 28.4 years (SD = 5.0). Most participants were European-American (95%, n = 19) and had less than a college education (see Table 1). A majority had experienced an opioid overdose (85%, n = 17), with 80% of the sample overdosing at least one time on heroin and 40% overdosing at least one time on pain pills. Participants were in treatment an average of 10.8 days (SD = 4.5) prior to their participation in the interview, and 65% of patients had previously attended inpatient treatment.

Table 1.

Participant characteristics.

(N = 20)	% (n) or mean (sd)
Gender
Male	60% (12)
Female	40% (8)
Average Age	28.4 (5.0)
Race/Ethnicity
European American	95% (19)
Non-European/Minority	5% (1)
Experienced an Overdose	85% (17)
Heroin overdose	80% (16)
Pain pill overdose	40% (8)
Days in Treatment (Tx)	10.8 (4.5)
Previously Attended Inpatient Tx	65% (13)
Naloxone
Naloxone Awareness	95% (19)
Have (had) Own Kit	45% (9)
Have Used Kit on Someone Else	35% (7)
Have Had Kit Used on Them	45% (9)

Themes

Five main themes were identified during the content analysis: (1) naloxone awareness and access, including, content knowledge and source information for naloxone; (2) intersections between naloxone access and drug selling; (3) naloxone availability while using, including attitudes about naloxone, occasions with no naloxone availability, when naloxone is “good to have,” and when naloxone is a priority for users; (4) changes in opioid use behaviours associated with naloxone access, and (5) naloxone behaviours that alter overdose mortality risk, such as how users distinguish when to use naloxone, dis-incentives to naloxone use, and solo opioid use. All themes and subthemes, as well as definitions and illustrative quotes are presented in Table 2.

Table 2.

Key themes and illustrative quotes.

Theme
Naloxone Awareness and Access	Knowledge	What participants know about naloxone.	Just that it can save your life on overdose. It saved mine. (Participant 08, 33.7 year old male) I know that it’s used to bring people back from overdose, and it’s to block the receptors in the brain. It tricks the receptors in your brain. (Participant 16, 38.6 year old male)
	Source	Where participants gained knowledge about naloxone.	I don’t think the information is presented out there. Even when I was in outpatient, they didn’t really tell us where to go and get it. I know they give it out some places, ‘cause I know they train people on that kind of stuff, but I didn’t know directly where to go. (Participant 03, 29.7 year old male) A couple of friends of mine that I knew of it and then once I enrolled at the Needle Exchange, I became aware of it. And then just you hear through the grapevine, you just hear from the people on the streets and whatnot. Now when I actually seen it is when it was administered on me for the first time when I overdosed. (Participant 12, 29.0 year old female)
	Access	Whether participants have a naloxone kit.	It was never that easy for me to get … [] … I was the only one that I ever know that had one. (Participant 14, 25 year old male)
Intersections between Naloxone and Drug Selling		Participants talked about how selling drugs was something that happened for them to survive (“survival selling”) and how they would ensure naloxone access while doing so	Definitely changes people’s minds about selling heroin. It changes my mind about selling heroin. Just the survival selling, which I’ve done before. It’s definitely changed my mind about that. ‘Cause if he [another dealer] can get charged any of us can. (Participant 19, 28.0 year old female)
Naloxone Availability While Using	Attitudes about naloxone	What feelings or attitudes participants had about naloxone.	A lifesaver. Everyone should be able to have it. I’ve overdosed three times and each time I’ve been Narcanned. It wasn’t pleasant, but it saved my life. I’d be dead without it … so, it’s a lifesaver. (Participant 20, 22.4 year old male) I carry it around just in case (Participant 16, 38.6 year old male)
	No naloxone availability	Participants indicated no attention to or need for naloxone while using. They did not have naloxone available when they used opioids.	We didn’t care about hurting ourselves. We didn’t care about [naloxone], we just wanted to get high and nothing else was on our minds. I can see if we would have had a close friend in the circle who was using with us died as a result of painkillers. I think then maybe it would’ve been a little bit of a wake up call to either get a kit or stop using in general. But we never brought it up. (Participant 10, 20.4-year-old male)
	“Good to Have”	Participants felt that naloxone was important or “good to have” but they did not make any additional efforts or attempts to have naloxone while using.	I actually, me using, I’ve been in some really dangerous, risky situations where it just wasn’t a priority to people that I was with. It wasn’t a priority for them. My one friend’s house that I told you about, where most of the time I had seen the kit, she would be like, “Just be careful, I don’t have no more Narcan.” or “I’m out,” or “I only have one Narcan,” and “Who’s doing what?” Like she would keep an eye. But otherwise, I would be all over the ghetto, in the rural neighborhoods of the trap houses and drug dealers where everything was real quick cop and go, hit and go. So the whole focus and the necessity or the priority of having it was just next to none. (Participant 12, 29.0 year old female)
	Priority	Participants emphasized the importance of having naloxone and made specific plans to ensure naloxone availability.	If I have a group of people at my house and we’re all sitting around there hanging out and talking, I make sure it’s right out in the open so that way everybody can see it. (Participant 06, 28.8 year old female)
Changes in Opioid Use Behaviours	No changes in opioid use behaviours	Participants indicated that having naloxone did not change how much or how often they used opioids.	Nobody wants to have to get Narcaned. So it’s not like ‘oh, I have Narcan, I can use as much as I want’ because you don’t want to be Narcaned. You just don’t want to fall out [overdose] period. It’s not a pleasant experience. (Participant 19, 28.0 year old female)
	Have changed opioid use behaviours	Participants indicated that having naloxone did change how much or how often they used opioids.	I knew that it was fentanyl and that there was a potential that I could overdose. And I told him to get his Narcan ready because I knew what I was about to do, and I fell out just like that. And actually, he had two of them, two Narcan things, that he had to administer. Because when he did the first one, I didn’t wake up. And then the second one was the one that woke me up. (Participant 09, 27.2 year old male) I’ve had guys joke about it, whose had the Narcan. It’s funny, [chuckle] used to make me crack up laughing, he’s like, “Oh, don’t worry,” he’s like, “you can totally do too much.” He’s like, “I’ve got Narcan, I’ll just bring you back.” (Participant 13, 24.4 year old male)
	Opioid use after naloxone administration	Participants discussed the sick feeling (withdrawal) that follows immediately after naloxone administration and stated that this feeling made them want to use opioids again as soon as possible to counteract the withdrawal.	Actually, [I] had a friend, three days in a row he died and got brought back by naloxone. And every time he got brought back from the hospital, he would leave the hospital and go and use again. And then the next day he went and used from the same person, died again and got brought back. And then he did it for a third day and did the same thing. (Participant 17, 26.3 year old male)
Naloxone Behaviours that Increase Overdose Mortality Risk	Distinguishing When to Use Naloxone	Participants indicated there was uncertainty about when to use naloxone.	A lot of times people mistake an overdose for a nod. And that’s where a lot of people have ended up dying because people thought they were just in a nod. But remember I told you that [my] brother was like, ‘Oh, leave her alone, you’re gonna mess up her high, just let her do a nod.’ And really, I was overdosed. I was like this [participant demonstrated folded forward] and I overdosed, and I wasn’t in a nod! (Participant 12, 29.0 year old female)
			The heroin addict’s biggest fear is illness, is getting sick from withdrawal so you don’t wanna do it to somebody else that you’re hanging out with but then at the same time, you don’t wanna … ‘Cause that’s the other thing too, all of this stuff is really embarrassing but you strive for the point right before overdose. The point of highness right before overdose. So high that you’re sloppy and falling over and all that stuff, so basically, for me to Narcan somebody, they gotta stop breathing. (Participant 19, 28.0 year old female)
	Dis-incentivized Naloxone Use	Participants discussed several reasons why they would not want to use naloxone and/or would hesitate to use naloxone.	Pissed off that they were Narcanned, because they were immediately sick, but that’s better than being dead. (Participant 02, 26.1 year old female). Yeah, because usually if you’re a consistent heroin user, it’s gonna put you in instant withdrawal. No one likes to do that, you kill their buzz. And then not only that, it’s like they can’t really get high for a little bit, because they’ve got the Narcan in them, so it’s gonna be a waste if they go to do another shot. That’s just the sickening things about drug addicts, you half die and then fucking do more drugs that almost killed you right after coming away from it. (Participant 13, 24.4 year old male)
	Solo Opioid Use	Individuals who use primarily by themselves, in an isolated environment.	my only downside to it, is that I tend to use alone, because I live in a family where these types of things are not obviously acceptable, you know what I mean? And my friends don’t, I usually work and things like that. When it comes to using, I’m usually alone. So in the instance of having a kit, I think the only time it would be beneficial, is if I were using with people and something were to happen. (Participant 05, 26.6 year old male)

Naloxone awareness and access

Most of the participants were able to identify naloxone as the “overdose drug” (n = 19, 95% of sample). Their knowledge about naloxone varied, from general awareness to specific information about the brain (Table 2). However, one participant was not familiar with naloxone at all, stating “I don’t even know what it is” (Participant 18, 28 year old female). Her lack of knowledge may be because she was an isolated user and only began sniffing opioids because her intimate partner taught her how to do so.

Despite most participants having at least some knowledge about naloxone, many did not feel their peers had that same knowledge. One participant felt that his fellow users knew what naloxone was, but they did not have additional information, such as where to get the kit. Further, participants indicated that they did not know they were permitted to have a kit, such as this participant who stated “I’ve just never really had the opportunity to, or let’s say even the knowledge that I could. Until I came here [treatment centre], I didn’t know that you could just have a kit chillin’ in my house” (Participant 05, 27 year old male).

Overall, 45% (n = 9) of participants previously had a kit of their own, and 35% (n = 8) used a kit on a fellow opioid user. These individuals received kits from outpatient treatment and/or the local needle exchange program. In addition, as this participant states, social connections were an important source of knowledge because “most people know what’s available at the needle exchange because of word of mouth from between each other” (Participant 19, 28 year old female). However, another participant concluded, “if I went to the needle exchange I definitely would have grabbed it [naloxone kit], but I never went because one of the other people I was using with always had hundreds of fresh needles” (Participant 02, 26 year old female). She identified a potential key barrier to naloxone access as only those users who access the needle exchange program would be able to get naloxone kits there.

Others knew about naloxone from their personal experiences with overdose. For example, “the first time I overdosed is when I found out about it, they [the Emergency Medical Technicians] told me that that’s what they had used” (Participant 16, 39 year old male).Friends’ overdoses were also a source of naloxone knowledge for participants. Usually, participants became aware of naloxone through multiple avenues, including friends, the needle exchange program, and outpatient treatment. Finally, some participants talked about how specific geographic areas were more isolated from naloxone information, that while common to hear about naloxone in the city, “you never hear about anything like Narcan and this s**t in the suburbs” (Participant 14, 25 year old male).

Naloxone access varied widely for participants. One participant found naloxone was difficult to obtain and he was the only individual in his network with a naloxone kit (Table 2). This participant’s experience is in contrast to two participants in this sample who had extensive naloxone access; participants 04 and 11 individually discussed acting as the naloxone source for fellow users. Participant 04 discussed, “I’ve been the one to supply them [naloxone kits], because my fellow users they’ve never tried to reach out and get help, but they have asked me for the kits” (Participant 04, 22 year old female). This participant talked about how she had 10 or 11 kits in the past year alone and used seven of them on fellow users. Participant 11 also talked about being the source for her group, making sure that fellow users always knew she had her kit with her.

Other participants talked about how they would keep naloxone kits in their cars, “throw it in their glove box, or in their centre console” (Participant 09, 27 year old male). This is particularly important as participants described an urgency to use opioids, and preferred to use in locations that were quickly available. For some participants this meant they would use in the car. While some would use when the car was stationary, others talked about using opioids while driving, including one participant who talked about how “people that sniff it, you can just drive down the road, have someone hold the wheel, hurry up, snort it, and you’re done. It’s not the smartest thing to do, but a lot of people do it” (Participant 08, 34 year old male). Therefore, keeping naloxone in the car may provide a quick access point for such individuals, despite potentially risky driving behaviours (such as using opioids while operating a vehicle) that may result.

Intersections between naloxone access and drug selling

Participants talked about how they would engage in ‘survival selling,’ or selling drugs in order to fund their own opioid use, and how they would want to have naloxone while doing so (participants, not researchers, developed and used this term). Selling was fairly common, with five participants (25%) indicating they had sold drugs or participated in ‘survival selling.’ Several participants talked about this, particularly those with a longer history of opioid use. As one participant states,

I felt like it was my responsibility if I was going to sell someone a bag of heroin, [and] not know how their body would react to it, that it was my responsibility to save a life. I was never in it to kill anybody, I was never in it to hurt anybody intentionally. So I guess I was just trying to do the right thing in a wrong situation.

(Participant 06, 29 year old female)

She was adamant about her consistent naloxone access and ensuring those who purchased opioids from her would also have access to naloxone, if required. For this participant, she felt it was a moral choice to ensure access, stating at one point that her mother felt she did so in order to soothe a “guilty consciousness.” Other participants talked about drug dealers having naloxone kits because, as one participant stated, “if somebody dies off of their product, they can catch a homicide charge” (Participant 05, 27 year old male).

Naloxone availability while using opioids

Participants generally felt positively about naloxone, often calling it “a lifesaver,” while others expressed a sense of gratitude for naloxone, “I was thankful for it. And I know this other girl too, she was thankful for it ‘cause it saved her life” (Participant 08, 34 year old male). Generally, participants felt that naloxone should be widely carried, as one participant stated “I think it’s a good idea for everybody and anybody to have it.” (Participant 15, 31 year old male). Some participants were more reserved, often talking about naloxone as “Just in case I overdose. My parents know about it, so just in case” (Participant 14, 25 year old male). There were also participants who felt that carrying naloxone was impractical despite its value, stating “you can’t really carry that. I’ve got tight pockets and it’s so big” (Participant 17, 26 year old male).

Second, several participants indicated they did not have naloxone available while using opioids. These participants offered several reasons for this, the most common of which was they never thought that they would need naloxone. Others described indifference about the consequences of their use, such as one participant who ignored the consequences and instead focused on the ‘high’ he was looking to achieve (Table 2). He identified lack of overdose experience as one reason why he and his group of friends did not recognize the potential severity associated with their use.

Third, participants talked about how naloxone was “good” to have, but specific plans were not made to ensure naloxone availability. As one participant stated,

No, I was never like, ‘Make sure you got naloxone when we go and cop [use] this time, just in case.’ I’ll be on the way to go and get somethin’ and be like, “Anybody got Narcan, just in case?’ They’d be like, ‘Nah,’ and it’s not like, ‘Okay, well, let’s stop and get Narcan.’ It’s like, ‘Oh, alright. Well, I guess if somebody OD’s, we’re f****d.

(Participant 09, 27 year old male)

The participant clearly saws the danger with overdose, but indicated he is not willing to alter his opioid use to make sure that he had naloxone available.

Finally, some participants prioritized naloxone availability while using opioids. Some participants would make a careful plan for naloxone use. For example, one participant indicated,

So, every time we went to use, I showed ‘em with my kit. I didn’t wanna lead with it, but I said, ‘If anything happens to me, or if anything happens to you, I’m gonna use this, and it’s not gonna be feelin’ okay when you get up.

(Participant 11, 26 year old female)

This participant made sure to have the naloxone kit available whenever she used; she was adamant about this throughout her interview. In addition, another participant spoke of how having naloxone ‘was just as important to me as having a clean needle’ (Participant 04, 22 year old female).

Changes in opioid use due to naloxone

There were three main categories when participants described how naloxone access might have influenced their opioid use. First, some indicated that naloxone did not change their opioid use at all. One participant emphasized the negative qualities of overdose and indicated those consequences outweighed any potential benefits from changing opioid use amount or frequency (Table 2).

On the other hand, some participants expressed strong statements that naloxone access changed their use behaviours in term of quantity and frequency. One participant stated that “you can do plenty more [heroin] if you have Narcan, because the chances of overdosing are much greater” (Participant 02, 26 year old female). Several participants described different ways naloxone access changed opioid use patterns. For example, one participant described how a user’s wife would remain sober while he used, “Yep, I have it [naloxone]. My wife has it, she stays right next to me, I get high. In case I die, then they give it to me” (Participant 08, 34 year old male). It should be noted that other participants felt having a ‘sober’ friend to administer naloxone if needed was “just silly … [] … You’re not gonna hang out with a bunch of heroin addicts and not get high. That’s just weird to me, what would be the fun in that or any enjoyment in that?” (Participant 01, 36 year old male).

Others talked about how naloxone diminished concerns about mortality associated with opioid overdose, such as, “I’ve seen people, instead of doing four bags they’ll do eight because they’ve got the Narcan laying around” (Participant 02, 26 year old female). These users talked about how naloxone access allowed them to chase a bigger high,

I’ve seen a couple of my friends use it as like a … [] … just a security. They would get high knowing they have it, knowing they can fall [out], trying to get to that place to be able to fall out [overdose] and then have someone bring them back.

(Participant 17, 26 year old male)

As this participant described, his user group would try to overdose because of the feeling it caused, while not worrying about any associated mortality. Another participant talked about how naloxone was “an excuse just to be more dangerous, I guess, do a bigger shot” (Participant 02, 26 year old female).

The ‘safety net’ aspect of naloxone was particularly important for those who suspected heroin was cut with fentanyl. For example, one participant discussed asking a fellow user to get his naloxone kit ready because he knew the opioid he was about to use had fentanyl in it and was going to use anyway (Table 2). Others discussed the idea of tolerance dictating if/when naloxone would be needed. One participant felt he did not need to have naloxone available because “when you’re consistently buying the same product, you know what you can handle and what you can’t” (Participant 13, 24 year old male). He continued, talking about the uncertainty with this approach, particularly for users with a lower tolerance.

but there were certain people, say like me and another buddy, we’d go down with two other people, people who don’t have too much of a high tolerance, we go, ‘Okay, wait ‘til we try it first and let you know how it is, and we’re gonna let you know what you can handle.’

(Participant 13, 24 year old male)

For these users, naloxone was not the ‘safety net’ they used; rather, they would stagger use order, allowing those with a greater tolerance to go first and relay the experience to those with less tolerance. Participants described such situations as “smart” use, or using opioids in ways that may minimize their risk for overdose.

Finally, participants repeatedly talked about immediate opioid use after naloxone administration. Several participants described the ‘horrible’ feeling after being revived with naloxone, and that “people wanna get high right away after they take Narcan too, ‘cause they’re sick” (Participant 19, 28 year old female). Another participant stated his friend overdosed three days in a row because he used opioids shortly after being released from the hospital (Table 2). An additional participant shared a very similar story, with a friend who “got hit with the Narcan, went to the hospital but refused detox, and went back out, and right back at it” (Participant 07, 39 year old female).

Naloxone behaviours that alter overdose mortality risk

Participants discussed several aspects of naloxone administration that could potentially change mortality risk from overdose. First, participants described an uncertainty about when to use naloxone when others are overdosing. As one participant describes, “you wanna make sure that they’re overdosing and not just really high and you wanna make sure that you can’t wake up any other way” (Participant 19, 28 year old female). Importantly, this quote illustrates that the decision to administer naloxone is complex and involves weighing whether the person’s high will result in death. However, as another participant discussed, she felt that often people were not able to recognize a ‘true overdose,’ stating that she felt users would mischaracterize an overdose as someone experiencing a high (Table 2).

Other participants described a great deal of uncertainty around the true definition of an overdose, with some participants stating that ‘falling out’ is the same thing as an overdose, while others felt that the individual needed to stop breathing and have blue lips to truly be considered an overdose. ‘Nodding out’ for some seems to be the “goal” of using opioids, with one participant describing the difference as:

Nodding out, that’s just being high I guess. When people are just like slouching. I mean the falling out starts off like that, and then when they’re completely incoherent, they’re starting to turn white and blue, starting to choke, that’s when it turns into falling out. But that’s the street term [for overdose], I guess.

(Participant 13, 24 year old male)

In this quote, the participant distinguished between ‘nodding out’ and ‘falling out,’ which he defined as a street term for overdose. Others described ‘nodding out’ and ‘falling out’ to be equivalent. Overall, participants lacked consensus on how to define ‘nodding out,’ ‘falling out,’ and overdose.

Some participants talked about dis-incentives to using naloxone; the primary reason was concern over ruining someone’s high. For example, one participant talked about how his friend became very irritated and aggressive because of the naloxone, stating,

he was f***ing pissed, he was like, ‘I was just f***ing taking a nap, I wouldn’t have died.’ He’s like, ‘What the hell?’ and this and that. I was like, ‘Dude,’ I was like ‘people don’t turn blue when they f***ing sleep. You weren’t f***ing taking a nap.’

(Participant 13, 24 year old male)

Others had similar experiences, indicating that naloxone administration was not always a welcomed response while using opioids.

Participants also discussed the dangers of using alone, particularly as no one would be able to administer naloxone if necessary. As one participant described, “I would use by myself, and I’d use it anywhere and everywhere. In my car, in the bathroom, wherever. Wherever and anywhere” (Participant 15, 31 year old male). Participants identified this type of use as particularly dangerous because “no matter how many Narcan kits you have, if people are using alone, they’re gonna die ‘cause they can’t Narcan themselves when they fall out” (Participant 19, 28 year old female).

Discussion

The present results indicate that naloxone awareness (Theme 1) is very common among opioid users. However, depth of knowledge varies, with some individuals being highly educated about naloxone and others just able to identify naloxone as “the overdose drug.” In addition, less than half of the study sample had ever had their own naloxone kit and even fewer had ever used a kit on a fellow user. This variation could be understood in the context of our previous findings, in which an overdose education and naloxone distribution (OEND) program did not have any individuals attend who were currently using opioids or had experienced an overdose (Heavey et al., 2017). Other OENDs have expressed challenges in recruiting long-term opioid users for take home naloxone programs (e.g., Banjo et al., 2014). As a result, if OEND programs are not recruiting current opioid users, it is unlikely these individuals would learn of and obtain naloxone. Several participants indicated that they obtained clean needles and naloxone simultaneously at the local needle exchange program; it is possible that those participants were more familiar with naloxone because both services were available at the same location. Taken together, these results suggest that OEND programs are not fully reaching their target audience and drug users are seeking naloxone in places where they may be more comfortable, such as needle exchange programs. Treatment programs may be a better place to educate those who use opioids on naloxone use and signs of overdose, particularly as relapse rates are high and the risk for overdose increases after treatment discharge (Clark et al., 2015; Moore et al., 2014; Scott, Foss, & Dennis, 2005).

Participants indicated they engaged in ‘survival selling’ (Theme 2) to sustain and fund their opioid use and believed naloxone was an important resource while doing so. This is particularly salient as drug dealers are being held criminally liable if someone overdoses on heroin they sold (Gyryta, 2016). While naloxone possession seems to be motivated by the drug dealers’ concerns over the legal ramifications of overdose, an unintended consequence was more responsible naloxone access behaviours among these participants. In light of the high overdose rates, particularly when the heroin is mixed with fentanyl, any opportunity to increase naloxone access in the drug user community is beneficial, regardless of motive.

There was a wide range of beliefs expressed about naloxone availability while using opioids (Theme 3). Some participants did not make any efforts to have naloxone available, and others felt that it was “just as important as a clean needle.” For a select group of participants, naloxone access seemed to be opportunistic: if it was available, they would keep it around, but they would not make specific plans to get naloxone nor would they change their use patterns to make sure they had naloxone available. It is possible that experience with opioid overdose may influence participant’s perception of the value of naloxone, such that those who had witnessed an overdose may be more inclined to carry naloxone. Observing an overdose can be stressful or traumatic, and individuals who had saved someone’s life by administering naloxone often described that feeling as ‘heroic’ (Wagner et al., 2014). More research is needed to fully understand why some drug users are adamant about naloxone access and others assign it low priority; the differences in naloxone priority was a new and surprising finding of this study. For overall overdose prevention, research and advocacy groups could focus on making naloxone a social norm for opioid users.

In addition, there were two participants who were unique in their naloxone access. These individuals had “hyper-naloxone” access, possessing several kits each and using kits on users in their network multiple times. In this way, they served as a naloxone resource for other users in their network, thereby increasing the potential to reverse overdoses. This can be understood in the context of social network influences on substance use, in which drug users can alter drug use patterns of others. One example of this is when fellow injection drug users can aid non-injection users, helping them to transition to injecting heroin (Neaigus et al., 2006). Further, understanding why these two participants felt so compelled to carry, distribute, and administer naloxone could be important to consider when developing naloxone distribution programs. As other research has found greater odds of nonfatal drug overdose is associated with a larger drug-using network (Latkin, Hua, & Tobin, 2004), it is possible that naloxone could permeate networks in a similar way to reduce opioid overdose mortality. Examining peer support as a possible intervention to widen naloxone access is an important future direction for this work.

Critically, there were participants who expressed changing their opioid use behaviours as a result of naloxone availability (Theme 4). Primarily, participants discussed changing how much heroin they used in a given situation; they indicated using more heroin to achieve a bigger high. This finding may fit within the context of sensation seeking as an integral part of drug use behaviours. Sensation seeking is marked by activities that increase the amount of stimulation for a given experience (Roberti, 2004). Within this framework, it is logical that sensation seeking drug users would look for ways in which to obtain a greater high through increased opioid dose. Our study participants endorsed naloxone as one way to facilitate increased use by enabling larger amounts to be ingested/injected without the concern of dying from an overdose. This is consistent with concerns expressed in other research (Green et al., 2013; Rudski, 2016).

Participants talked about using opioids shortly after an overdose to reduce withdrawal symptoms brought on by naloxone administration. Several participants with a long history of opioid use stated that they did not use naloxone to experiment with opioid dose/frequency because the experience of naloxone administration (i.e. precipitated withdrawal) is so unpleasant. These findings may suggest that experienced users were not motivated to experiment but are using to mitigate withdrawal and thus are indifferent about naloxone access (e.g., Participant 19’s statement in Table 2). Future research should examine sub-groups of opioid users and determine if the reasons for continued use may change. There may be a sub-group of opioid users who are more prone to experimentation and thus more interested in using naloxone for other reasons, such as those with a relatively short opioid use history. More experienced opioid users may also have a false sense of security regarding their risk for overdose; these individuals may be particularly vulnerable if their supplier has opioids with greater potency (e.g., fentanyl).

Participants discussed several naloxone behaviours that could increase their risk for overdose (Theme 5). Particularly, there was difficulty determining when to use naloxone as they were concerned with “ruining” someone’s high. This also served as a dis-incentive to using naloxone, especially as participants expressed concern over using naloxone only if it were really needed. This finding potentially reduces the effectiveness of naloxone distribution programs as timely naloxone administration is crucial to overdose reversal (Boyer, 2012). Further, these findings emphasize the need to clearly educate opioid users to identify an overdose and distinguish when to use naloxone on others. This education should also include the dangers of using opioids alone as no one would be available to administer naloxone in an overdose situation.

These results should be understood in the context of a few limitations. First, the present results may not generalize to all opioid users as this used a relatively small sample of individuals in residential substance use treatment. Currently there is very little information on the intersection of naloxone access and opioid use; we felt it was important to begin by exploring themes in a way that would give us a rich understanding and an initial picture of how opioid use and naloxone access influence each other. This then allows us to better guide future research, particularly with key questions that resulted from the one-on-one interviews. Such questions include why naloxone access behaviours differ among opioid users and how to leverage social networks for naloxone distribution. Second, the present study used a sample of individuals in treatment for opioid use; it is likely that a sample recruited from outside treatment centres would have different experiences with naloxone. By including those who met criteria for needing treatment, we felt that the sample would provide the best opportunity to gain initial understanding of how naloxone access might shape long-term opioid use. Future research should access a broader sample and include opioid users who are not in treatment or occasional users.

Taken together, these results indicate that though naloxone awareness is high, there is great variation in the attitudes, beliefs, and practices associated with naloxone access. Though participants generally felt naloxone was an important resource, not all were inclined to carry it or use it appropriately. Future research needs to examine why different groups of drug users access and administer naloxone differently, particularly to identify those at risk for experimental opioid use while carrying naloxone. This could be accomplished using additional qualitative research with a variety of opioid users, including those who are not in treatment and those in outpatient treatment. In addition, descriptive epidemiological research could begin to address these questions and provide information on longitudinal trends with larger sample populations. Exploring how naloxone awareness, access, and attitudes change over an extended period of time may provide important insights into changing opioid use behaviours. In addition, research needs to consider what distinguishes the “hyper-naloxone” individuals within their social networks, and how such habits could be leveraged for naloxone distribution and overdose prevention.