Motivation to Carry Naloxone: A Qualitative Analysis of Emergency Department Patients

Abstract

Purpose:

Our aim was to explore perspectives of patients who received naloxone in the emergency department (ED) about (1) naloxone carrying and use following an ED visit and (2) motivation for performing these behaviors.

Design:

Semi-structured interviews of patients prescribed naloxone at ED discharge.

Settings:

Three urban academic EDs in Philadelphia, PA.

Participants:

25 participants completed the in-depth, semi-structured interviews and demographic surveys. Participants were majority male, African American, and had previously witnessed or experienced an overdose.

Methods:

Interviews were recorded, transcribed and analyzed using content analysis. We used a hybrid inductive-deductive approach that included prespecified and emergent themes.

Results:

We found that naloxone carrying behavior was variable and influenced by four main motivators: (1) naloxone access; (2) personal experience and salience of naloxone, (3) comfort with naloxone administration, and (4) societal influences on naloxone carrying. In particular, those with personal history of overdose or close friends or family at risk were motivated to carry naloxone.

Conclusions:

Participants in this study reported several important motivators for naloxone carrying after an ED visit, including ease of naloxone access and comfort, perceived risk of experiencing or encountering an overdose, and social influences on naloxone carrying behaviors. EDs, health systems, and public health officials should consider these factors influencing motivation when designing future interventions to increase access, carrying, and use of naloxone.

Purpose

Opioid overdose deaths has quadrupled over the past two decades, and there were over 90 000 drug overdose deaths in 2020, the majority involving opioids.^1,2 A strategic cornerstone in reducing death is distribution of the opioid overdose reversal agent naloxone.² Laypeople can safely and effectively administer naloxone to reverse overdose and community education with naloxone distribution is associated with decreased overdose mortality.^2–4 Further, modeling studies of policy strategies for mitigating overdose deaths suggest that distribution of naloxone show great promise for saving lives over the next five years.^5,6 Despite this, little is known about optimal ways to reach individuals at high risk of experiencing or witnessing an overdose and strategies which optimize naloxone carrying and use among this population.

Emergency Department (ED) visits offer an opportunity for engagement of high-risk individuals in overdose prevention interventions, particularly in light of increasing ED visits to EDs for nonfatal overdose during the pandemic.^7,8 Naloxone prescribing and distribution is recommended from the ED for opioid use disorder (OUD), and studies show high acceptance of take-home naloxone by ED patients.^9–11 Yet, at-risk ED patients rarely receive naloxone prescriptions.^12,13 Even among patients who do have access to naloxone, rates of carrying naloxone were low, with 74% of participants in one study reporting never or rarely carrying it.¹⁴ In another study, in which 53% of patients prescribed naloxone reported witnessing an opioid overdose within a year, an overwhelming majority (88–95%) stayed by the victim’s side but only 16% had administered naloxone.¹⁵

Little is known about how at-risk patients access naloxone, their naloxone carrying habits, and their comfort with naloxone administration. For patients who receive naloxone in other settings, barriers to carrying naloxone range from difficulty accessing the medication, lack of motivation, challenges of introducing a new behavior to a routine, or stigma.¹⁶ Prior work in behavioral design strategies has demonstrated that targeting motivation, lowering barriers to change, and designing a supportive environment can lead to desired behavior change.^17–19 However, there is a limited understanding of patient perspectives related to motivation for naloxone carrying, which if better understood could inform behavioral strategies to influence carrying and use within patients at high risk of witnessing or experiencing overdose.

The objective of this study was to explore perspectives of patients who received naloxone prescriptions from the ED about (1) naloxone carrying and use following an ED visit and (2) motivation for these behaviors. With increased understanding of how patients at risk for witnessing or experiencing an overdose respond to ED naloxone prescriptions, we can develop targeted interventions to improve the uptake and use of naloxone in the community to prevent opioid overdoses.

Design

This study included semi-structured, in-depth interviews of patients seen and discharged from the ED and who had received a prescription for naloxone at discharge.

Setting

This study took place in Philadelphia which had 1200 drug overdose deaths in 2020.²⁰ We recruited participants from two EDs within a large, urban academic health system in Philadelphia, including a large tertiary referral hospital and a level 1 trauma center, which together see >1000 OUD-related visits annually. All study protocols and instruments were reviewed and approved by the Institutional Review Board (IRB #842821) of the authors institution.

Participants

Participants were identified and invited to participate based on receipt of a discharge prescription for naloxone, either paper or electronic. The decision to prescribe naloxone was at the discretion of the treating clinician at the time of discharge. The EDs in this study had different protocols for discharging patients with naloxone. Some patients had their prescription for naloxone filled and dispensed while in the ED, while other patients had to go to a pharmacy to have their prescription filled. Most patients received the intranasal naloxone formulation (Narcan^®, Adapt Pharma Inc), including those who received take-home naloxone dispensed in the ED. This formulation was dispensed to patients as a box that includes two single use nasal spray doses that is FDA approved for bystander opioid reversal.²¹

A total of 205 people were solicited for study participation via text message, 162 (79%) participants did not respond, 3 (1.5%) participants responded and declined, and 40 (19.5%) participants initially responded and enrolled in the study. Of those 40, 25 (12.2%) completed the in-depth interview, the remaining 15 did not respond to follow up messages to schedule the in-depth interview. Following the interview, participants completed a brief demographic survey. Additional clinical information about the participants was abstracted from the electronic medical record by a member of the research team who was not involved in clinical care (HS) and stored securely. Of the 205 participants who were solicited for participation, 144 (70%) had a discharge diagnosis of substance use or a substance use disorder, 50 (24.3%) participants had a discharge diagnosis of a painful condition, and 11 (5.3%) had a discharge diagnosis of a painful condition and substance use or a substance use disorder.

Interviews were conducted via phone from November 2020 to February 2021 by a trained interviewer (HS) who was not involved in clinical care. Interviews ranged from 10 to 30 minutes. Participants who completed the interview received $50 USD for their time.

Interviews were audio-recorded, transcribed, deidentified, coded and analyzed using NVivo 12 (QSR International Inc, Burlington, MA). Interview transcripts were reviewed against audio recordings for accuracy. We followed the COREQ criteria for reporting qualitative research.²²

Methods

Informed Consent Process

All eligible participants were contacted using secure, HIPAA-compliant text messaging through the WayToHealth platform.²³ The initial text message obtained electronic consent to receive subsequent text messages, provided study information, and collected self-reported patient responses. In addition, patients could opt out at any time by texting “STOP”. Participants then answered a brief series of text-messages confirming their receipt of naloxone and inquiring about their interest in participating in a semi-structured telephone interview. A consecutive sample of those who expressed interest were contacted to schedule a telephone interview. Prior to beginning the telephone interview, participants went through an informed consent process with study staff that detailed the study purpose, protocol, and potential risks and benefits. The IRB provided a waiver of documentation of informed consent, and verbal consent was obtained and documented by study staff prior to beginning each interview.

Interview Guide Development

A semi-structured interview guide was designed to explore the habits, experiences, and perceptions of naloxone by the participants (see Appendix 1). The guide included open-ended questions and probes to expand upon answers as needed. Content focused on eliciting attitudes, beliefs, and perceptions of being prescribed naloxone in the ED, access to naloxone, and strategies for improving naloxone use. The interview guide was developed based on prior literature in other populations and setting and with input from experts in ED-based substance use and harm reduction interventions (AKA, ML, MKD and JP).^24–26 The interview guide was also reviewed by a person with lived experience and another patient navigator, both of whom provide support and care for patients with substance use disorders in an ED context. Finally, we pilot tested with 2 patients prior to formal data collection to refine and clarify interview guide content.

Data Collection

Semi-structured interviews were conducted via telephone by a trained, non-clinical team member (HS) who had experience interviewing patients and was not involved in participants’ care. Prior to enrollment, research staff verified inclusion and exclusion criteria. Interviews were recorded and transcribed, and identifiers were removed. The investigators intermittently reviewed transcripts as interviewers were being conducted to assess for thematic saturation, and interviews were conducted until saturation was reached.

Data Analysis

We used thematic content analysis to analyze the transcripts with a constant comparative coding approach.^27–29 Interviews were analyzed through an iterative process by two investigators (AS, HS) who met routinely to review and refine coding. Codes were developed through a hybrid inductive-deductive approach, with some prespecified codes identified based on the interview script and others developed after reviewing the transcripts for emergent themes. We then compared codes for fit until all themes that emerged from the transcripts had a code. Codes that were redundant with other codes that explained a broader set of themes were eliminated. Five interviews were selected at random for duplicate coding with an initial inter-rater reliability of a median weighted kappa of .93. Any coding differences were discussed until agreement was reached and adjustments were made to the codebook as necessary.

Results

Twenty-five participants completed the in-depth, semi-structured interviews and demographic surveys. Participants were majority male (60%) with an average age of 36.8 years. 48% were African American and 40% were White. The majority (72%) of participants had Medicaid, and 72% were stably housed. The majority (72%) of participants had previously witnessed a drug overdose, and 48% had a personal history of overdose (Table 1).

Table 1.

Demographics of Study Participants.

Characteristic	Study Group (n=25)
Age, mean (SD)	36.8 (11.3)
Gender, no. (%)
Male	15 (60%)
Female	10 (40%)
Highest level of education, no. (%)
Some high school or less	1 (4%)
High school graduate or GED	8 (32%)
Some college	6 (24%)
Associate degree	2 (8%)
Bachelor’s degree	6 (24%)
Unknown/Not reported	2 (8%)
Race, no. (%)
Black or African American	12 (48%)
White	10 (40%)
More than one race	3 (8%)
Ethnicity, no. (%)
Not Hispanic or Latino	23 (92%)
Hispanic or Latino	2 (8%)
Housing status, no. (%)
Permanent housing, stable	18 (72%)
Recovery house	2 (8%)
Shelter	1 (4%)
Unhoused	1 (4%)
Couchsurfing/staying with friends or family temporarily	1 (4%)
Permanent housing, unstable/worried about losing it	1 (4%)
Unknown/Not reported	1 (4%)
Insurance status, no. (%)
Medicaid	18 (72%)
Private/Employer	4 (16%)
Medicare	2 (4%)
Uninsured	1 (4%)
Personal history of overdose, no. (%)
Has previously overdosed	12 (48%)
Has never previously overdosed	12 (48%)
Prefer not to answer	1 (4%)
Witnessed an overdose (%)
Has previously witnessed an overdose	18 (72%)
Has never previously witnessed an overdose	4 (16%)
Prefer not to answer	3 (12%)

Qualitative Findings

In semi-structured interviews, participants described their experiences accessing naloxone after their ED visit and from outside sources as well as naloxone carrying habits and use of naloxone in their community. Frequency of naloxone carrying was variable among participants, ranging from reports of carrying naloxone every time they left the house to never carrying it.

Motivation to carry naloxone was highly influenced by reliable access to naloxone, perceived risk of encountering and overdose, and personal experience with overdose response. Comfort with encountering and responding to overdose was also cited as a motivating factor. In addition to individual factors, motivation also related to broader social norms and perceived stigma towards naloxone. Finally, participants described the impact of the pandemic on their ability to access and use naloxone. The major themes and supporting quotations are discussed in the text below, with additional quotes in Table 2.

Table 2.

Examples of Thematic Quotations.

Theme and Example Quote	Illustrated Point
Frequency of carrying Naloxone
“I carry it every day. It’s in my room. It’s in my bag.” (participant 23)	Some participants carry naloxone all the time
“I keep it at home. I don’t really go out much, but sometimes I might go somewhere I might throw it in the car.” (participant 20)	Some participants rarely carry naloxone
Naloxone acquisition
“I would also plug into a free library on electric Avenue, where they give out … stuff like that. They had the program started up where they were giving me suboxone, not suboxone, the narcan and they was giving me different things, the free needles, the alcohol swabs and stuff like that.” (participant 5)	Some participants get naloxone from harm reduction organizations
“Well, I usually go to the pharmacy. I now buy it on the street, because I don’t have a prescription to get the narcan from the pharmacy anymore” (participant 6)	Some participants get naloxone from pharmacy and the street.
“Yes. I only have actually one left and that’s the one that’s the one that was prescribed to me. And that’s the only one I have left. I don’t have access to get it anymore. Like I said, they used to go up in the emergency room and they would give them to you.” (participant 2)	Some participants get naloxone from the emergency department
Personal experience and salience “I carry the narcan, I’m just going to tell you, I carry the narcan because my brother died of an overdose and he died in the street, they found him dead and he overdosed and that’s why I know how to use it, to save someone else and their life.” (participant 10)	Some participants’ experience of have having family members die from opioid overdose motivated them to carry naloxone
“I know for a fact now, and I’ve witnessed it, that it saved my life. No, I’ll tell you, I won’t let nothing prevent me from carrying that with me because I know that it could save my life, because it did twice. So nah, I wouldn’t let nothing get in the way. I wouldn’t let nothing prevent me from carrying the narcan.” (participant 13)	Some participants’ experience of having naloxone reverse an opioid overdose they experienced motivated them to carry naloxone
“If I could save a life, why not. So, it’s a relief to me that I can help someone. If I can help someone, why not? (Participant 19)	Some participants’ abstract thoughts motivated them to carry naloxone
Comfort with Naloxone administration “My comfort levels, probably like a 10 … because I know howto do it, I’ve done it before, and I would change lives. I’m good with it.” (participant 14)	Some participants were very comfortable with administering naloxone
“I was thinking. I don’t know. I don’t think I would be [comfortable]. I think I’m not really sure. Like I said, I never thought about” (participant 17)	Some participants were uncomfortable with administering naloxone
Stigma associated with naloxone
“It was a little embarrassing. It was embarrassing. And then, the way people look at it, when something, well, people around Kensington already know. A lot of people know Narcan. They always think, they call people drug addicts or something. So, you don’t want to hear all that. So, it was embarrassing. (Participant 1)	Some participants reported that societal stigma associated with drug use caused embarrassment around carrying naloxone
“No, just, when I’m on a job or something, I just don’t want everybody to see that I’m carrying narcan. Some people are okay with it, some people aren’t okay with it.” (participant 6)	Some participants reported peer perceptions of them carrying naloxone made the less likely to carry it
Impact of COVID-19
“Yeah, it has, because you’re really not able to get into the emergency room unless it’s really, really an emergency. And some people don’t see drug use and stuff like that as a big emergency … until the last minute. Until an OD. That means it’s over. It could have been avoided.” (participant 19)	Some participants reported that the COVID-19 pandemic made it more difficult to go to the emergency department
“Because they used to give it out on the street in certain neighborhoods, but they’re not doing it anymore, because with the corona and everything that’s going on.” (participant 2)	Some participants reported that the COVID-19 pandemic made harm reductions organizations harder to access

Naloxone Acquisition

Participants identified ease of access to naloxone as one important factor influencing naloxone carrying habits. While all participants received a naloxone prescription during their ED visit, the majority also reported accessing naloxone outside of the ED. Non-prescription sources identified by participants included community harm reduction organizations, purchasing naloxone from other individuals, or sharing naloxone within their community networks. Many participants also accessed naloxone through non-ED prescriptions, either through an individual prescription from a physician or via the state standing order, which allows people to access naloxone at a pharmacy without a personal prescription. A number of participants who reported prior naloxone access reported had multiple sources of naloxone. One shared:

“I’ve got some from the doctor, once I shared with them that I was using. They gave me a prescription for it. Then I got some from the truck that goes around. I forget where it’s from, the place it’s coming from, but they give out the free supplies and other things, so that’s where I got it from.” (Participant 7)

There was a subset of participants for whom the naloxone prescribed in the ED was their first experience with this medication, demonstrating that prescription or community naloxone distribution efforts were not reaching everyone at high risk.

Personal Experience and Salience

Motivation to carry naloxone was also highly influenced by participants’ perceived personal risk of overdose or the overdose risk of those around them. Prior experience administering naloxone to others, personal experience with OUD, or loss of a loved one from overdose were all things that increased the salience of overdose risk and served as motivators to carry naloxone regularly. One participant shared,

“Usually I will have [naloxone] on my person and then throughout the house. And because I live with [a person who uses opioids] too, and just because I’ve had opioid abuse disorder for a while, and it’s helped bring me back like two times so far.” (Participant 21)

Many participants reported a conscious decision-making process about whether to carry naloxone based on their plan for the day and their perception of how risky it was. These participants viewed their need for naloxone as sporadic and only carried it with them when perceived risk was higher, such as personal substance use or travel to an area with public substance use. For example, one participant reported they rarely carried naloxone, except when they thought it might be needed:

“Not unless I’m going out with people that use [drugs].” (Participant 12)

Participants who carried naloxone frequently acknowledged the relative ease of carrying naloxone and the enormous benefit of reversing an overdose:

“It’s always in my car or in my apartment…Usually if I know I’m doing something I’m not supposed to do, I’ll bring it with me.” (Participant 15)

“What are some things that get in the way of you carrying Narcan?” (Interviewer)

“Really nothing. I don’t really see a reason not to carry it.” (Participant 15)

Those who rarely or never carried naloxone often reported lower perceived risk of encountering an overdose. However, some participants shared that the sporadic naloxone carrying at times left them feeling vulnerable in the event they had to respond to an overdose:

“Yeah, so I have never administered it myself. I’ve never had it on hand. But I have had friends in the past who were addicted to opiates, and I mean, sometimes I wish that I had had it. I’ve never been in a position where I needed to administer it, even if I was carrying it.” (Participant 4)

Comfort with Naloxone Administration

Participants were asked about their comfort with administering naloxone, as it was hypothesized that perceived self-efficacy with naloxone administration may impact perceptions of carrying naloxone. The majority of participants felt comfortable with the process of recognizing an overdose and administering naloxone, often citing the intranasal formulation’s ease of use. A few participants reported lower levels of comfort with the medication or process, mostly related to unfamiliarity with the device and concerns of improperly administering the naloxone. Among participants who expressed comfort with administering naloxone, there were variable levels of willingness to intervene for a stranger vs a friend or acquaintance, with greater hesitation from some participants in administering naloxone to a stranger. Those with more experience with receiving or administering naloxone were also aware that administration could be more complex when evaluating an individual in public, the potential response of the person receiving the naloxone, and the fear of causing harm.

“Because you got to be safe on how you’re doing it. There’s a lot going on, so I be nervous about that. I don’t want to make the wrong mistake and then end up having something else. So when you’re giving it to somebody, I second guess. But if it really needs to be done, I’ll do it. I get nervous when I do that. Because really, you never want to do it wrong where something happens. So I do get nervous giving it to somebody.” (Participant 1)

This group of individuals identified that while naloxone administration is simple, the context of an overdose often is not, highlighting a challenge for community overdose reversals. Personal experience with using naloxone was discussed by some participants as a reason they felt comfortable with future use in bystander overdose reversal.

Stigma Associated with Carrying Naloxone

Along with ease of access, salience, and comfort with naloxone administration, participants acknowledged broader social factors as important influences on naloxone carrying. Participants reported that the stigma with using opioids would be associated with them if they were seen carrying naloxone. In particular, stigma associated with carrying naloxone was reported as a barrier. One participant shared:

“I said most people wouldn’t be as understanding as a doctor or anybody that’s educated around Narcan. So they’ll be judging it.” (Participant 19)

There was a more specific concern that size of the intranasal naloxone would be conspicuous and coworkers, family members, or strangers in public would judge someone if they could recognize the delivery device on them.

“I believe that it being as big as it is, and it’s really, the word is big, big. So it makes people uncomfortable to carry because everybody is going to know what you’re doing, what you did.” (Participant 20)

While some reported that they carried naloxone despite the perceived threat of judgment, this was an additional barrier for less motivated participants. Opinions of family members and coworkers seemed particularly influential in worry about stigma for naloxone carrying.

Impact of the COVID-19 Pandemic

The study was conducted during the pandemic and participants were asked directly how the pandemic affected their use and access to naloxone. Many reflected on the social and economic impacts of the pandemic and how that changed drug use. Participants reported that the economic hardship and social isolation of the pandemic were drivers of substance use and increased the frequency of using alone and other high risk situations. Others reported that the social distancing that the pandemic required kept them away from people that might influence them to use opioids and decreased their drug use and need for naloxone.

“I know a lot of people that had a lot of clean time, me personally had a lot of clean time. I relapsed, went back out, because the pandemic, like I said again, the recovery point of it, doing events, going to events, going to bowling, doing the bingo, just doing stuff like that, going to meetings, it’s just, they’re not having meetings anymore. Everything’s on video and it’s just not the same.” (Participant 6)

A few reported harm reduction organizations were not distributing naloxone as frequently during the pandemic, increasing the difficulty of accessing naloxone

“I only have actually one [naloxone] left and that’s the one that’s the one that was prescribed to me. And that’s the only one I have left. I don’t have access to get it anymore. Like I said, they used to go up in the emergency room and they would give them to you. Used to.” (Participant 2)

This COVID-19 pandemic-related reduction in naloxone access was a concern to these participants, as they described difficulty in accessing naloxone when they felt they needed it. A few participants endorsed that they had stockpiled several boxes of naloxone during the pandemic because it was viewed as a more scarce resource.

Discussion

Participants in this study described their experiences acquiring, carrying, and administering naloxone and the factors that influenced these behaviors. Most participants carried naloxone when they perceived high personal risk of overdose or high risk for those around them, which varied based on personal experience, comfort level, and environment. Despite acknowledging the lifesaving nature of naloxone in overdose reversal, many participants described stigma related to carrying naloxone as a potential barrier.

This study adds to the literature in several key ways. First, we explored participant motivation for carrying naloxone and how this impacts their habits, finding that their perceived risk for experiencing or encountering an overdose was a major driver of behavior. Studies have shown that consistently carrying naloxone was associated with higher rates of actually administering naloxone.³⁰ There is also emerging evidence that patients incorrectly estimate the risk of needing naloxone, one study found that participants who injected opioids more often throughout the day were less likely to think they would need to use naloxone.³¹ Given the unpredictable nature of overdose, this should encourage naloxone prescribers to engage in conversations about the risk of overdose and provide guidance on when to carry naloxone. This finding can also inform future interventions, which may need to incorporate communication about overdose risk as part of efforts to increase naloxone uptake.

Second, our study highlights important barriers and facilitators to naloxone carrying, which are critical understand as having naloxone immediately available is important in overdose reversal. We found that personal experience with overdose and motivation to save someone else’s life were major facilitators of naloxone carrying. This result aligns with prior survey findings that motivation to save a life was associated with higher rates of accepting naloxone.³² We also found that perceived stigma was a significant barrier to naloxone carrying. Prior work found that patients were concerned about the stigma of being labelled an “addict” when accessing naloxone.³³ Additionally, social stigma from medical professionals has been associated with lower likelihood of prescribing naloxone, and stigma from family members may make patients less likely to bring up their opioid use.³⁴ This study adds to this finding, as almost all the participants described stigma from strangers, coworkers, or family members as a barrier to carrying naloxone. Some participants also indicated that being educated about naloxone can modify the stigma associated with it and thus possibly reduce a barrier to carrying naloxone. Highly motivated patients, however, were more inclined to carry naloxone despite these responses, suggesting that this barrier is modifiable.

The results of this study could be used to inform public health messaging, including strategies to increase the rates of community naloxone uptake that overcome stigma or other barriers to carrying naloxone. Other studies have found that over 90% of laypeople provided overdose education will assist the victim.¹⁵ However, in order to effectively reverse an overdose that layperson must be carrying naloxone. Our findings were in line with behavior change frameworks, suggesting that increasing the ease of acquiring naloxone, increasing motivation to carry naloxone, and reducing stigma around carrying naloxone may all increase the likelihood of patients reversing an opioid overdose with naloxone.¹⁷ When naloxone is prescribed in EDs, providers can make naloxone easier to access and use by dispensing naloxone directly to at-risk patients in the ED and providing education on recognizing and reversing overdoses. Even low resource interventions can be effective; one study found that even just an informational pamphlet produced sustained knowledge in principles of overdose recognition and treatment.³⁵ Other interventions in EDs and elsewhere could increase motivation through reminding patients of the lifesaving ability of naloxone and decreasing the stigma associated with carrying naloxone, other themes impacting motivation in our study. Finally, reminders or other cues for habit formation that have been effective in other settings - combining a naloxone device with something else that is carried daily such as a wallet or keychain - may be helpful to test in future studies to for increase naloxone carrying rates.³⁶

In addition, the COVID-19 pandemic has had widespread social and economic impacts that changed the way people interacted and affected patterns of substance use. Some participants described increased opioid use related to isolation and boredom. They also described riskier patterns of use, such as using alone. Many participants also described reductions in access to substance use treatments and harm reduction services, including naloxone. Combined with the patterns of riskier opioid use, this may be contributing to the increased morbidity and mortality seen in national data on opioid overdoses.¹ Combatting the dual crises of COVID-19 and overdose underscore, more than ever, the importance of capitalizing on every opportunity to intervene to promote harm reduction interventions prevent and reverse opioid overdose.

Our study has several limitations. First, we interviewed a small sample of patients from three EDs in a single city during the COVID-19 pandemic, and participants were limited to those with phones, so the results may not be transferable to other settings of when patients might try to access and carry naloxone. Because of the small sample size we were unable to assess how attitudes around naloxone carrying might vary by race and gender, however a larger study should be performed to further investigate racial and gender differences. Additionally, participants in the study were a mix of patients with discharge diagnosis of substance use related conditions and painful conditions, but data was not gathered on the presence of concomitant substance use disorders in the patients with painful conditions. Another limitation is that not all patients were dispensed naloxone at the time of discharge, and instead had to leave the ED with a prescription to be filled at a pharmacy. Dispensing naloxone at the time of discharge may impact the salience and perception of carrying naloxone compared to receiving a prescription. The participants in this study were at high risk of overdose as many had personally overdosed or witnessed an overdose, thus the results may be less transferable to a population at lower risk of overdose. Also, as participants were discussing potentially sensitive information, their responses may have been subject to social desirability bias. Several steps were taken to reduce this bias, including refining the interview guide with input from individuals with lived and harm reduction experience, using an experienced interviewer to ask questions in a non-judgmental fashion, and to have an interviewer who was not involved in the clinical care. Finally, because this study was conducted during the COVID-19 pandemic, interviews were conducted virtually and may not reflect patients experiences and observations in non-pandemic times.

Conclusions

In interviews with patients, we found several key factors influenced motivation to carry naloxone, including ease of naloxone acquisition and comfort with use, prior personal experience with OUD or overdose and perceived future risk of encountering and overdose, and social influences such as stigma on naloxone carrying behaviors. Our findings are critical for informing future strategies aimed at increasing motivation for naloxone carrying at the individual clinician, health system, and public health level. Such strategies are required now more than ever as the COVID-19 pandemic has reduced access to traditional harm reduction services.

Appendix

Motivation to Carry Naloxone: A Qualitative Analysis of Emergency Department Patients

Interview Guide

Q1: Are you carrying Narcan now?

Prompt: if answers yes “do you plan to continue carrying Narcan”, if answers no “do you plan on carrying Narcan”

Q2: Do you currently carry Narcan

Prompt: clarify frequency if necessary, example “Can you tell me how often”

Q3: Can you tell me about your experiences with accessing and finding Narcan to carry?

Prompt: clarify getting Narcan example “how do get Narcan to carry?”. Further prompt to further discuss more details about where they get it such as doctors office or pharmacy, and how they feel about it

So What? (Implications for Health Promotion Practitioners and Researchers)

What is Already known on this Topic?

Laypeople can safely and effectively administer naloxone to reverse overdose and community education with naloxone distribution is associated with decreased overdose mortality. Emergency Department (ED) visits offer an opportunity for engagement of high-risk individuals in overdose prevention interventions.

What Does this Article Add?

Little is known about how at-risk patients access naloxone, naloxone carrying habits of patients, and patients’ comfort with naloxone administration. Most participants carried naloxone when they perceived high risk of overdose. Despite acknowledging the lifesaving nature of naloxone in overdose reversal, many participants described stigma related to carrying naloxone as a potential barrier.

What Are the implications for Health Promotion Practice or Research?

Future strategies aimed at increasing motivation for naloxone carrying at the individual, health system, and public health level should be aimed at reducing stigma associated with carrying naloxone and reducing barriers to receiving naloxone.

Q4: Do you have any challenges with getting Narcan?

Prompt: can further probe nature of barrier, example “is cost an issue”

Q5: Can you tell me about your family, your friends, or anyone else in your support system? Can you tell me about their familiarity with Narcan?

Prompt: clarify if people around them know what Narcan does, share Narcan, know how to use Narcan, have used Narcan in past

Q6: What are some things that get in the way of you carrying Narcan?

Prompt: clarify the nature of the issue, such as forgetting to carry it, size of device.

Q7: How comfortable are you giving someone else Narcan for an overdose?

Prompt: clarify their comfort level example “if they would feel comfortable giving to someone else”

Q8: have you ever been in a situation where you or someone else that you know needed Narcan for an overdose?

Prompt: ask them to describe the situation.

Q9: Has COVID-19 pandemic impacted your use of substances or the substance use of people that you know around you?

Prompt: ask about substance use patterns, meetings, or how COVID-19 has impacted life.

Q10: Has COVID 19 impacted your ability to find Narcan?

Prompt: ask about community resources or ability to see medical providers

Q11: we would like your input about developing tools that might help people make it easier for people to carry Narcan and find Narcan. So can you describe how you’re carrying Narcan now?

Prompt: ask how they carry Narcan for example “do you carry Narcan in your backpack”

Q12: how do you think we could increase interest in Narcan?

Prompt: ask about family interest.

Q13. is there any other information that you want us to know about your experiences with Narcan