Participants in both focus groups expressed mixed feelings about naloxone in the context of overdose, including some hesitation to its distribution for take-home use. In our review of transcripts, we identified four major themes to capture the overall views of participants: 1) support for naloxone as a lifesaving measure; 2) challenges of administering naloxone during an overdose; 3) fear of dopesickness; and 4) fear of police arrest at the scene of an overdose after naloxone administration.
Naloxone as lifesaving measure
Study participants unanimously recognized the potential role of naloxone in successfully reviving someone from an unconscious, overdose-induced state. Not surprisingly, most enthusiastic were participants who had already completed the Overdose Prevention and Reversal Program and received naloxone. As one participant described:
"This particular program with the naloxone...gives me a feeling of, of security. And not so much for myself, because...to tell you, to be honest, I've been using...heroin now for close to 30 something years and I have never once overdosed... However, I have a lot of friends, and a lot of my close friends...are also users, so...it gives me a feeling of security for them. To be able to help them, just in case one of them goes off the deep end...and overdoses... At least...I feel like a guardian angel, I guess."
These words demonstrated both an understanding of the breadth of fatal overdose – that is, any drug user is at risk – as well as a personal commitment to saving the life of a friend, however possible. Another participant expressed similar sentiment. She shared her experiences intervening in overdose scenarios over the years. Compared to the unproven and potentially dangerous resuscitation methods such as causing pain and applying ice, she described naloxone as "such a godsend" because she now "can give 'em that before the ambulance" arrives. The administration of naloxone to an overdose victim while awaiting more comprehensive medical care was imperative to this participant, considering both the urgency of a non-breathing individual, and the fact that ambulances are sometimes not as quickly dispatched to overdose calls. She explained, "A lot of times, fifteen, 20 minutes, if the ambulance doesn't show up, [the overdosed person] could be dead." Naloxone provided her not a substitute for calling 911 but a sense of security while awaiting an ambulance.
Non-naloxone-holding participants also voiced support for the potential role of naloxone to revive someone. However, they pointed to its merit as a necessary step only when other attempts proved unsuccessful and the consequence of death would be too much to bear. One participant stated:
"Narcan is good, when you're like, it's the last resort. I mean, you can't get them up, you put 'em in the shower, you rubbed ice on their scrotum, you've given them mouth-to-mouth resuscitation, you've pumped their chest, you've tried."
Another participant confirmed that he would "rather have narcan than die," despite the unpleasant symptoms of withdrawal that sometimes accompany its use. These participants, in particular, were clear about their support for naloxone, and furthermore, qualified the exact circumstances in which they would use it.
Challenges of administering naloxone
Accounts of naloxone perception and experience were not entirely favorable. Participants reported challenges and fears when they reflected upon personal experiences of naloxone being administered to them or their administering it to others.
An overdose situation can be scary, chaotic, and emotionally traumatic. Bystanders untrained in proper overdose response may become paralyzed with fear or attempt to revive the person using less effective measures. In anticipation of police involvement, others may be overwhelmed with securing their own safety, frantically discarding evidence of drugs or drug paraphernalia, or planning their escape in fear of being charged with manslaughter. The sight of an overdosing friend or family member can also be distressful. The stress of an overdose situation was clearly described by focus group participants with extensive overdose experience. As one participant put it:
"Every time I've been in the situation where someone ODs, it's a panic, and ...I've always kept my cool, but everybody else around and yellin' and screamin'...and losin' their head, and...runnin' round like a chicken with their head cut off...they're scared for this person's life."
When naloxone is available, the situation is not necessarily improved. Among focus group participants, only one reported administering naloxone to an overdosing friend, who was then revived. He described the situation as hectic, himself struggling to remain calm enough to perform the injection with precision and ease.
"And you don't want to make a mistake, you know? You don't have to look for a vein...but...it's a very shaky...scary situation... I'm not looking for directions... You're nervous as hell!"
Administering naloxone can be even more complicated when the person trained to administer it is himself intoxicated. The same participant explained, "especially if you're messed up... and all five people are... high as a kite, you know... it's gonna be total panic." For this participant, the difficulty of administering naloxone, compounded by the fear that his intoxication level may pose additional barriers, were so profound that he was reluctant to receive a naloxone refill. Although he recognized the vital role of naloxone in the outcome of the event, he was unsure he could use it again.
Fear of dopesickness
Dopesickness – or opiate withdrawal characterized by shaking, headache, nausea, and vomiting – was a prominent theme among study participants. Naloxone, particularly in larger doses, can incite withdrawal symptoms in opiate users. Focus group participants who had been given naloxone by emergency medical personnel described the effect as "the worst feeling in the world." In recounting his overdose experience, one participant reported being revived with only mild discomfort after a single naloxone injection, but when EMS administered a second dose, the physical result was unbearable:
"I was COLD... I was SWEATIN'...I was freezin'...like somebody just took the plug out and 'Oh, no. That pleasure is gone' ...having fever and chills at the same time... Everything hurts. Your whole body hurts. Uh, 'cause you're convulsing."
Other participants who had been given naloxone during an overdose confirmed reports of excruciating pain, citing that it was not an experience they wished to repeat.
Enduring dopesickness post-naloxone use presented further concerns for some study participants, who affirmed that if naloxone were ever used on them, they would have no choice but to use more opiates to ease the discomfort. As one participant noted, after naloxone, "Now you're ill again, so you gotta get MORE money to get high, 'cause now you're sick!" Another added, "You gonna have to go cop again... So even if you don't wanna, you're gonna go get it anyway." The perceived need to counteract withdrawal by using again highlights a common misconception. In truth, because naloxone only lasts 30 to 90 minutes after administration, any additional opiate consumption increases the chances of a subsequent overdose once the naloxone wears off. The above study participants, who had some naloxone experience but no formal training, were therefore familiar with its function and physiological effect but lacked important information that would lead to effective follow-up care.
Even some of the participants with formal naloxone training were misguided on how to proceed once administering naloxone to an overdosing friend or family member. They understood the risks of subsequent overdose with increased opiate use, but were not convinced that waiting until the naloxone wears off qualified as best practice. Speaking hypothetically about reviving someone with naloxone, one participant explained:
"If I had the money, I would think I would like to get 'em straight, but I'd be afraid he'd go right back into overdose, so I wouldn't do it. But if anything, I would give 'em a little methadone."
Although the study participant demonstrated an awareness that both dopesickness and subsequent overdose are associated risks of naloxone, his prioritizing immediate withdrawal relief could be potentially dangerous. Dopesickeness, unlike overdose, is non-fatal and in cases where naloxone has been administered, will subside without further medicating. A subsequent overdose could also be effectively reversed; however, it would require additional doses of naloxone that may be unavailable to the overdose responder.
Fear of police
The final theme presented by the focus groups was fear of police involvement at the scene of an overdose after naloxone administration. These fears were less about individuals having drugs on them when police arrived, and more about liability if they used their naloxone on a third party, which at the time of writing was legally suspect. Such fears were compounded by past experience, in which police officers rarely elicited information before performing arrests, and furthermore, treated all drug users at the scene of an overdose as responsible parties. In reflecting upon situations where she would use naloxone, one participant stated:
"There is the police factor... So you might be more scared about the damn cops than saving someone's life. So that's the choice you gotta make. You might be facin' some serious time."
Participants who shared this view requested additional training in how to effectively communicate with police officers who arrive at the scene of an overdose, particularly if they have used their naloxone on someone without a naloxone prescription.
The desire to save another person whatever the consequence, however, overpowered these fears in the case of other participants. One participant explained, "If I see a person's life on the line, my first thought would be, the first thing, to just bring them revival." Using naloxone beyond its recommended purpose, from his view, was a risk worth taking.