Findings are grouped into four distinct themes: naloxone availability, training, naloxone utilization, and emergency response.
Participants described their experiences initially obtaining naloxone, overall accessibility of naloxone, and alternatives used during an overdose emergency when naloxone was not available.
A majority of participants learned naloxone was available through syringe exchange programs or through peers. Others heard through local media, health service providers, employers, or by observing naloxone being used during an overdose emergency.
Naloxone rescue kits were sought by many participants because they were active opioid users and recognized a personal vulnerability regarding overdose risk. Several had friends or family members who were opioid users and/or had witnessed an overdose emergency, as explained by one participant who stated, “people have a tendency to die in my apartment” (male, 68 years). The need to be prepared due to the risks of opioid use was emphasized by one individual who stated, “I always carry [a rescue kit] with me just because. I always have one in my backpack …” (female, age unknown). Others were concerned about the potential presence of fentanyl. One participant explained, “I’ve had other people OD on me and just, there’s a lot of problem with fentanyl around in dope and stuff” (male, 60 years). Overall, ensuring personal safety and safety for others by preventing an overdose death was a motivation for obtaining naloxone.
Participants described naloxone rescue kits as well-advertised and fairly easy to obtain, although some participants also noted that kits were occasionally out of stock. Many appreciated that organizations distributing naloxone had simple processes such as being able to, “...just go in there and ask for it” (male, 33 years) rather than, “...having to have some appointment and just some long process that makes it difficult to follow through” (female, age unknown). Most participants had positive interactions at community organizations when obtaining kits and found staff to be “knowledgeable,” “professional,” “friendly,” and “nonjudgmental.” The quality of experiences at the syringe exchange organizations made positive impressions. About the exchanges, one participant shared, “...if they sold [naloxone] at a store...I would still rather go to the needle exchange just because of how helpful they are and because they have experience” (male, 33 years).
Overall, travel time to obtain a naloxone rescue kit was minimal. Participants in urban settings described traveling up to 15 min by car or 30 min on foot while those individuals in more rural settings indicated travel times of up to 30 min by car. Those living in rural regions tended to obtain and maintain a larger supply of rescue kits (i.e., “several at a time,” “a whole bunch at a time”) compared to those in more urban regions. Many were able to receive multiple rescue kits at a given time to share with peers as secondary distribution was available to anyone who was trained and interested in supplying rescue kits to peers.
Participants identified few challenges in accessing naloxone. Barriers that were identified reflected both participants’ personal experiences and known peer experiences. The most commonly cited barrier was kits being out of stock or limited distribution hours. Other barriers, mentioned by a small number of participants, included fear of a confidentiality breach or a lack of desire to listen to training.
Generally, when people needed naloxone, they had a rescue kit available and did not require an alternative to reverse an opioid overdose. A small number of participants transported victims to the hospital or asked for naloxone “on the street” when they did not have it available.
Participants highlighted the value and appropriateness of the brief, verbal naloxone training provided by community organization staff when people received naloxone rescue kits. A majority of participants reported being satisfied with training and felt it to be “self-explanatory” or “enough to get by on.” Several participants appreciated the printed materials included in the kit, but a few did not find them necessary. One perspective included, “You don’t really look into a pamphlet to find out how to use it” (female, age unknown). Another explained, “I did glance at [the instructions]. It’s a no brainer – what you’re supposed to do with [naloxone]” (male, 43 years).
Participants offered suggestions related to training. One participant recommended that training emphasize physical positioning of the victim’s head, saying “It’s some things that are important...tilt the head back...a lot of people don’t realize that, but it does make a difference. It helps [naloxone] get through better” (male, 43 years). Another suggested training also included “something about not needing to go farther than the instructions, like putting someone in a bathtub of cold water” (male, 36 years). For those who lacked confidence administering naloxone during an overdose emergency, participants suggested opportunities for hands-on training or “refreshers” when obtaining a refill, including “just a quick conversation asking if they know how to use it” (female, 40 years).
While training is intended to be a requirement for obtaining a naloxone rescue kit to ensure a person knows how to use it during an overdose emergency, a small number of individuals refused naloxone training when obtaining a rescue kit due to lack of time or overconfidence. One participant who had declined to listen to training when obtaining a rescue kit reflected that training would have been helpful in order to use the kit properly during an overdose emergency. Another participant described using a friend’s kit and reading the printed instructions quickly during an overdose emergency in order to administer naloxone.
Participants described personal experiences using naloxone, perceived effectiveness of a rescue kit, and general overdose prevention behaviors.
Participants were able to recognize opioid overdose signs and symptoms. Some described being the only person in a group who knew what to do during an overdose emergency. An experience of one individual who had administered naloxone was recounted as:
...my girlfriend at the time, one of her friends did a big, fat injection of heroin. He OD’d, and she called me freaking out. And everybody’s just standing around... “What do we do?” Nobody even bothered to call an ambulance. So I went there and gave him a shot up the nose of it and sat him up, got some cool rags to cool him down, made sure he was coherent. He snapped out of it pretty quick. (Male, age unknown.)
Prior to naloxone administration, many participants attempted to wake or stimulate victims in some way, although one participant shared that “I don’t waste a lot of time doing that, especially if the person isn’t breathing” (male, 60 years). Participants reported that, in addition to administering naloxone, rescue breathing was performed some of time, either by the participant or by others present during the overdose.
Participants most often used two 4-mg doses of naloxone nasal spray during an overdose emergency. Several recalled waiting up to 5 min after administering naloxone before giving a second dose. All victims awoke after receiving naloxone.
All participants perceived naloxone to be effective and described statements such as, “It’s instant” and “Nobody’s died.” One participant shared, “It’s a frightening situation but [naloxone] has always worked for me. It hasn’t failed me yet” (male, 60 years). Although effective to reverse an opioid overdose, several participants shared that naloxone did not impact substance use behaviors, other than a short-term reduction in use following an overdose event. One participant explained:
...I try to choose every day, but it’s not that easy. I’d like it to be. But [naloxone] does help. You’re just, like, in shock that that had to happen to you. And when you come back you are just so grateful...you are just, like, ‘If this [naloxone] wasn’t here, I would be dead.’ ...I want to live; everything in me does. But as far as just choosing not to use the drug, I wanted to use right after that. (Female, age unknown.)
A few participants thought people were less cautious about their drug use because of the availability of naloxone. According to one person, “People feel like they don’t have to be as careful when using when having [naloxone] around” (female, 43 years).
Additional overdose prevention strategies
Overdose prevention practices with groups varied across participants. For example, some individuals, especially those in rural communities, proactively designated a person responsible to administer naloxone if needed. Others informed peers about where naloxone was located in the room and reviewed how to use it. An approach taken by one was to occasionally ask peer users if anyone had [naloxone], “usually while we’re sitting around” (male, 43 years). Others did not usually discuss the topic except in cases when “...the heroin is strong” (female, 40 years). Another respondent indicated lack of planning and discussion about naloxone, saying, “I mean, you just try not to overdose, you know?” (male, 68 years).
Some participants made plans with fellow users prior to drug use to prevent overdoses including doing a test shot or suggesting that peers initially reduce the amount of drugs used in order to determine potency. One participant shared:
For me, myself, no matter what, I always just try a little bit and tell people around me to try a little bit first, because you can always do more. You cannot do less, you know? That’s what I try to tell people. (Female, 43 years.)
Gender differences in overdose prevention strategies
Interestingly, when describing overdose prevention strategies, all female participants discussed safety behaviors they had engaged in due to potency concerns such as taking a test shot, starting slow, and waiting for another person (frequently identified as a male significant other) to try the substance first. Female participants also described warning others about the potency of a supply. Fewer than half of the male participants mentioned potency considerations in regard to prevention, with responses focusing instead on naloxone as intervention by letting others know that naloxone is available, where to obtain it, and its location when using.
Participants described their interactions with emergency services and first responders during overdose incidents. Overall, participants rarely called 911 during an overdose. Some stated they have never called 911; as explained by one participant, “Most of the time, people try to handle it on their own” (male, 40 years). Some participants described concerns about the potential impacts on their relationships with peers, as calling 911 “would be like being a snitch” (female, age unknown). A small number of those without a legal history or current legal involvement did call 911, particularly if feeling, “too nervous to handle the situation on my own” (female, 32 years). Most participants were distrustful of law enforcement and believed they would be treated “like criminals” or be charged with a crime for being part of the overdose situation. Participants were generally aware of the state’s Good Samaritan law but did not believe that it provided immunity.
Recommendations for awareness and availability
When asked for final thoughts or recommendations, participant responses largely focused on issues of awareness and availability. Those who reported having administered naloxone only once attended to issues such as awareness and personal security. This differed from participants who have administered naloxone on more than one occasion, with all of those participants providing a recommendation addressing availability and universal prevention options like including naloxone in first-aid kits, passing naloxone out in hospitals, and having naloxone in every household.