Overdose Risk Management and Compensation in the Era of Naloxone

ABSTRACT
As alarming rates of opioid-related overdose have come to dominate the national dialogue on drug-related
harms, the overdose reversal medication naloxone has expanded from the confines of emergency medical
personnel to the public domain. The rapid legislative response of many US states to the current epidemic of
opioid dependence and overdose has resulted in widespread initiatives to provide naloxone not only to
professional first-responders, but also to active opioid users. These initiatives have already demonstrated
their worth and are responsible for thousands of overdose reversals and lives saved. To date, however, two
important topic areas that bear on the ongoing success of overdose education and naloxone distribution
efforts remain unexplored. The first concerns potential gaps in knowledge about and access to naloxone
among people who use opioids but are not connected to opioid overdose prevention programs where the
bulk of outreach is conducted. The second concerns the largely unexplored behavioral and psychosocial
effects of surviving or “reversing” an overdose in which naloxone was administered and of simply having
naloxone present while engaging in overdose risk behaviors. Preliminary evidence suggests that these
impacts may involve different trajectories depending on individual and social-structural factors. For some,
reversing an overdose has been reported to empower individuals to maintain safe opioid use practices. For
others, naloxone provision has been met with a self-reported intention to use more opioids. Why naloxone
provokes such widely varying responses, and for whom it produces the most robust health benefits, remain
critically unexamined questions. To address these public health concerns, this study responds to the
current NIDA and FDA mandate for “additional formative and implementation studies of naloxone
distribution and overdose intervention in field settings, particularly for prescription opioid abusers.” Using a
mixed-method approach designed to yield richly contextualized findings, the proposed study will recruit a
sample of 600 people who use illicit opioids in New York City to: a) learn which subgroups of illicit opioid
users have been trained in naloxone, used it, or had it used on them, and why some continue to refuse
training; b) identify the risk-behavior impacts of using naloxone, surviving an overdose because of
naloxone, or having naloxone and a trained overdose responder present when using illicit opioids; and, c)
illuminate opioid users’ own perspectives on overdose risk management and naloxone’s role within that,
and identify social-structural and psychosocial factors underlying both positive and negative changes in
overdose risk behavior. Taken together, these objectives have the power to inform the tailoring and
targeting of existing outreach and education strategies and to guide the development of new intervention
tools for opioid users whose exposure to naloxone and overdose events may represent powerful turning-
points in their drug use careers and catalysts for positive behavioral change.

Grant Number: 5R01DA046653-05
NIH Institute/Center: NIH
Principal Investigator: Alexander Bennett