Abstract
Introduction.
Naloxone distribution remains a cornerstone of a public health approach to combating the ongoing opioid overdose crisis. Most distribution programs focus on providing naloxone to individuals who use drugs or those closely associated with them (e.g., family). Utilizing businesses as fixed location sources of naloxone could be a valuable supplemental strategy to preventing fatal overdoses that is underexplored in the literature.
Methods.
We surveyed business owners and employees (N=149) located in neighborhoods characterized by high rates of drug use in Baltimore City. Participants reported their interactions with people who use drugs as well as if they had heard of naloxone, if the business had naloxone on the premises, and how many employees were trained to use naloxone.
Results.
Most participants reported seeing individuals under the influence of drugs (93%), public drug use (80%), and overdose (66%) while at work. 66% of participants had heard of naloxone. Among those who had heard of naloxone, only 39% reported that there was a naloxone kit in the business and 28% of businesses had multiple employees trained to use naloxone.
Conclusions.
Businesses are underutilized as potential reliable sources of naloxone. While study participants reported high levels of exposure to drug use and overdose in and around their businesses, their ability to intervene was limited. Efforts to train employees to respond to overdoses and to keep naloxone on site are warranted to supplement existing naloxone distribution efforts and can help empower business staff to help prevent overdose mortality in their communities.
Keywords: Naloxone, overdose, businesses, harm reduction
Introduction
Community naloxone distribution is a cornerstone of the public health response to the ongoing opioid overdose epidemic in the U.S. (Clark et al., 2014; McDonald et al., 2017; Moustaqim-Barrette et al., 2021). This distribution strategy prevents fatal opioid overdoses by providing take-home naloxone kits and resuscitation training to community members who may witness overdose (McDonald et al., 2017). Typical organizations that distribute naloxone include syringe service programs, health departments, and other harm reduction programs that conduct outreach to people who use drugs (PWUD). There have also been efforts to increase naloxone distribution in medical settings, such as emergency departments when a patient presents with an overdose (Gunn et al., 2018; Samuels et al., 2018; Samuels et al., 2019).
Naloxone distribution has been widely demonstrated to reduce overdose mortality in a range of locations, both in the U.S. and internationally (Irvine et al., 2018; McDonald and Strang, 2016; Naumann et al., 2019; Walley et al., 2013). While widespread, further scale up of such programs is necessary as overdose death tolls continue to increase, fueled by the high prevalence of potent synthetic opioids in the drug supply. For example, overdose deaths in the U.S. exceeded 100,000 in a 12 month period for the first time between April 2020 and April 2021 (Ahmad et al., 2021). Preliminary research suggests that fully scaled naloxone programs could result in more than 120,000 naloxone administrations annually in the United States, saving countless lives (McAuley et al., 2015).
Most community naloxone programs focus on targeting individuals who may witness an overdose (Clark et al., 2014; McDonald et al., 2017), typically PWUD and their social network members (e.g., families). This approach does have limitations, as research has documented that people who receive naloxone often do not regularly carry it with them for a variety of reasons, ranging from fear of police harassment to simply forgetting the naloxone at home (Bennett et al., 2020; Burton et al., 2021; Khatiwoda et al., 2018; Tobin et al., 2018). Individual-level distribution also requires regular re-engagement with naloxone providers, as doses get used up. The need for re-engagement is a substantial barrier to adequate naloxone coverage, as research has shown that only about half of PWUD who have ever received naloxone currently have a dose in their possession (Kinnard et al., 2021). Select professional categories, such as law enforcement, are also targeted as they are often first responders to overdoses, even though they are not medical providers (Davis et al., 2015). Nontraditional professionals, such as librarians, have been targeted given elevated rates of overdoses in their bathrooms, but targeting such unconventional naloxone providers is relatively rare. However, such programs rely on individuals with naloxone in their possession to be at the scene of an overdose to be effective in preventing opioid overdose fatalities.
One potentially valuable strategy to supplement naloxone distribution to individuals is to establish fixed locations where naloxone is readily available throughout high drug use communities. The NaloxBox program is one such example, where plexiglass cabinets are installed on buildings and contain multiple doses of naloxone and instructions for how to resuscitate unresponsive individuals (Capraro and Rebola, 2018). Another complementary approach is to encourage business owners and managers to keep naloxone kits in the business and to train all staff how to respond to a drug overdose. People who work in high drug use areas likely witness many overdoses even though they may not use drugs themselves, though this has not been well studied. Businesses are potential fixed location sources of overdose response that can ameliorate some overdose response barriers in communities. Communities with naloxone in local businesses can rely on these fixed sites if naloxone is not on hand in the event of witnessing an overdose. It is unclear whether businesses in high drug use areas are keeping naloxone kits onsite, as, to our knowledge, no studies have specifically explored the presence of naloxone in businesses. We explored the proportion of business owners and employees witnessing overdoses, general naloxone awareness among this population, and the presence of naloxone in businesses in high drug use areas of Baltimore, Maryland.
Methods
Data are derived from the CONNECT study, which used a cross-sectional survey of business owners and employees in high drug use areas of Baltimore, Maryland to examine experiences with PWUD and their attitudes towards harm reduction programs. Data were collected in person between December 2019 and March 2020 and then by phone from April to July 2020 due to the Maryland shutdown in response to the COVID-19 pandemic. All study participants were adult (at least 18 years old) employees, managers, or owners of local businesses who reported working onsite at least 10 hours per week. Only one person was interviewed in each business. Businesses were in one of thirteen recruitment zones identified using spatial analysis of drug arrest data from the Baltimore City Police Department. Businesses within these zones were sampled using a multiphase strategy; during the first phase, we recruited a minimum of eight businesses per zone and randomly selected remaining businesses (using a random number generator) regardless of zone. In total, 149 surveys were completed, with one dropped from the current analytic sample for missing naloxone variables. Participants received a $15 VISA gift card for study participation. All study procedures were approved by the Johns Hopkins Bloomberg School of Public Health Institutional Review Board.
Participants reported if they had ever heard of naloxone (yes/no) and if there was a naloxone kit available in the business in case of an overdose (yes/no). Participants also reported how many staff members had been trained to use naloxone (reported continuously, recoded as 0, 1, or 2+). Participants described staff members’ experiences with drug use and overdose in and around the business and reported how frequently any staff members had witnessed any of the following in the previous 6 months which we then recoded into binary indicators of any such recent experience: high (intoxicated) people, overdose, public drug use, drug purchasing transactions, and discarded syringes. Finally, participants reported descriptive information about themselves (age, gender, race, education level, role in business) and the type of business (food, retail, or other).
First, we described the prevalence of naloxone awareness, having naloxone in the business, and the number of employees trained to use naloxone. We then used Pearson’s Chi Square tests to assess univariate relationships between measures of drug use in and around a business and business type with naloxone awareness and possession.
Results
Study participants were primarily men (56.8%), college educated (59.5%), an average of 40 years old, and about half (48.7%) were non-Hispanic Black (Table 1). One quarter (25.0%) owned the business and one third (35.8%) were managers. Businesses were relatively evenly distributed between food (29.7%), retail (35.1%), and “other” (35.1%) services. The “other” category included laundromats, gas stations, libraries, and barber shops/salons. Participants reported high rates of exposure to drug use while working. The vast majority (93.2%) had seen people who appeared to be under the influence of drugs, two thirds (66.0%) had witnessed at least one overdose at work, most had witnessed drug use (80.4%) and drug purchasing (75.0%), and more than half (57.2%) had seen discarded syringes on business premises. About two-thirds (66.2%) of participants had ever heard of naloxone. Among those who had heard of naloxone, roughly one-third (39.2%) currently had naloxone in their business. Approximately one-quarter (28.7%) of businesses had multiple employees trained to use naloxone. In bivariate analyses (Table 2), staff witnessing people who appeared to be high in the business, (χ=10.5, p=0.001), overdoses in and around the business (χ=7.3, p=0.007), public drug use (χ=5.2, p=0.023), and purchasing drugs (χ=4.9, p=0.027) were all significantly associated with naloxone awareness, while witnessing discarded syringes was not. Business type was also associated with naloxone awareness, such that participants from retail businesses were less likely to be aware of naloxone and participants from “other” businesses were more likely to be aware of naloxone (χ=8.6, p=0.013). Unlike for naloxone awareness, none of the measures of drug use in or around a business were significantly associated with having naloxone in the business. There were also no significant correlates of the number of employees trained to use naloxone.
Table 1.
Sample Characteristics, Business Naloxone, and Drug Use Experiences (N=148)
| N | % | |
|---|---|---|
|
| ||
| Age, M (SD) | 40.8 | 12.9 |
| Gender | ||
| Man/male | 84 | 56.8 |
| Woman/female | 64 | 43.2 |
| Race | ||
| Non-Hispanic White | 26 | 17.6 |
| Non-Hispanic Black | 72 | 48.7 |
| Other | 50 | 33.8 |
| Education Level | ||
| Less than high school | 18 | 12.2 |
| High school or GED | 42 | 28.4 |
| Some college or more | 88 | 59.5 |
| Role in Business | ||
| Owner | 37 | 25.0 |
| Manager | 53 | 35.8 |
| Employee | 58 | 39.2 |
| Business Type | ||
| Food | 44 | 29.7 |
| Retail | 52 | 35.1 |
| Other | 52 | 35.1 |
| Ever heard of naloxone | 98 | 66.2 |
| Had naloxone in the business (n=97) | 38 | 39.2 |
| Number of trained employees (n=94) | ||
| None | 47 | 50.0 |
| 1 | 20 | 21.3 |
| 2 or more | 27 | 28.7 |
| Staff witnessed high people | 137 | 93.2 |
| Staff witnessed overdose | 97 | 66.0 |
| Staff witnessed public drug use | 119 | 80.4 |
| Staff witnessed purchasing drugs | 111 | 75.0 |
| Staff witnessed discarded syringes | 83 | 57.2 |
Table 2.
Associations between Experiences with Drug use and Naloxone Awareness and Presence in the Business.
| Heard of naloxone | Had naloxone in the business | Number of trained employees | ||||||||
|---|---|---|---|---|---|---|---|---|---|---|
| No N (%) | Yes N (%) | χ, p | No N (%) | Yes N (%) | χ, p | 0 N (%) | 1 N (%) | 2+ N (%) | χ, p | |
| Business Type | ||||||||||
| Food | 16 (32.) | 28 (28.6) | 8.6, 0.013 | 21 (35.6) | 7 (18.4) | 4.0, 0.139 | 18 (38.3) | 3 (15.0) | 5 (18.5) | 5.4, 0.250 |
| Retail | 24 (48.0) | 28 (28.6) | 17 (28.8) | 11 (29.0) | 12 (25.5) | 7 (35.0) | 9 (33.3) | |||
| Other | 10 (20.0) | 42 (42.9) | 21 (35.6) | 20 (52.6) | 17 (36.2) | 10 (50.0) | 13 (48.2) | |||
| Staff witnessed high people | 41 (83.7) | 96 (98.0) | 10.5, 0.001 | 57 (96.6) | 38 (100) | 1.3, 0.251 | 46 (97.9) | 19 (95.0) | 27 (100) | 1.4, 0.502 |
| Staff witnessed overdose | 25 (51.0) | 72 (73.5) | 7.3, 0.007 | 40 (76.8) | 31 (81.6) | 2.2, 0.135 | 34 (72.3) | 14 (70.0) | 22 (81.5) | 1.0, 0.600 |
| Staff witnessed public drug use | 35 (70.0) | 84 (85.7) | 5.2, 0.023 | 51 (86.4) | 33 (86.8) | 0.0, 0.955 | 41 (87.2) | 17 (85.0) | 24 (88.9) | 0.2, 0.925 |
| Staff witnessed purchasing drugs | 32 (64.0) | 79 (80.6) | 4.9, 0.027 | 48 (81.4) | 31 (81.6) | 0.0, 0.978 | 42 (89.4) | 13 (65.0) | 21 (77.8) | 5.6, 0.061 |
| Staff witnessed discarded syringes | 25 (51.0) | 58 (60.4) | 1.2, 0.279 | 33 (57.9) | 24 (63.2) | 0.3, 0.608 | 29 (64.4) | 11 (55.0) | 16 (59.3) | 0.6, 0.756 |
Discussion
This is the first study, to our knowledge, examining naloxone familiarity and possession among businesses in high drug use areas in an urban center. Businesses in this study were highly impacted by drug use. Two-thirds of workers surveyed had witnessed an overdose at work in the past six months, indicating the importance of placing naloxone kits in businesses and training staff in overdose response. Awareness of naloxone was moderate, with two-thirds of participants having heard of naloxone prior to the study. The prevalence of naloxone in businesses was low, as only one third of those who had heard of naloxone reported having any at their business. All experiences with drug use at work were significantly associated with naloxone awareness in bivariate analyses. Having naloxone in the business was unrelated to employee experiences with drug use. Further, few businesses had multiple employees trained to administer naloxone. Interestingly, naloxone awareness, but not possession, was greater among those who reported staff members witnessing aspects of drug use while at work. These findings suggest that most businesses in high drug use areas of Baltimore do not keep naloxone kits on the premises, despite being aware of naloxone and having many experiences with drug use at the business.
Businesses have largely not been targets of naloxone campaigns, leaving a potential avenue to community naloxone saturation untapped. This is likely due to a perception that workers in these settings are not common witnesses or responders to overdoses in the community. Business employees in high drug use areas do in fact witness overdoses, as evidenced by 66% of our sample reporting that one or more staff members had witnessed at least one overdose in the past 6 months. Our data suggest that business owners and employees should be targeted by naloxone outreach programs as they are common witnesses to overdoses. Further, such outreach could enable other witnesses to know where they can find naloxone during overdoses if they do not have doses with them. Public facing indicators (e.g., window stickers, signs) can be implemented to inform PWUD and community members of where naloxone is available in case of emergency. Such strategies are potential complements to existing individual level naloxone distribution programs to reverse overdoses and save lives.
This study does have limitations to consider. Given the relatively small sample size, we were unable to conduct multivariable analyses. Despite this, our findings remain useful as a starting point for understanding how businesses may be potentially useful sources of naloxone. We were unable to explore reasons why businesses did or did not choose to have naloxone on their premises. Further qualitative work is warranted to understand why business owners and managers make this decision and how to plan programs to increase naloxone possession in businesses. It is also possible that some of the employees we surveyed were not aware of naloxone that may have been onsite or whether other employees had been trained to use naloxone. Nonetheless, this study is an important step in understanding how businesses are currently being utilized as naloxone access sites and how this could be expanded to combat drug overdose.
Conclusions.
In this study, we began exploring the potential role of businesses as sources of naloxone in high drug use areas. We found that owners and employees in such businesses broadly witness a range of drug use, including a large proportion who witness overdoses. Given that so many of these individuals witness overdoses, despite not necessarily using drugs themselves, naloxone distribution programs should target this population for outreach. Businesses are largely untapped fixed location sources of naloxone in communities highly affected by drug use and overdose. Expanding outreach to businesses and employees can help communities achieve naloxone saturation goals and prevent fatal overdoses.
Funding.
The CONNECT study was supported by the Bloomberg American Health Initiative. KES and SR were supported by a National Institute on Drug Abuse training grant (5T32DA007292). SGS is partially supported by the Johns Hopkins University Center for AIDS Research (1P30AI094189).
Footnotes
Conflicts of Interest.
None
Financial disclosure. Dr. Sherman has served as an expert witness in opioid litigation cases. No financial disclosures were reported by other authors of this paper.
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