Fentanyl harm reduction strategies among Latinx communities in the United States: a scoping review

Abstract

Purpose

Fueled by the prescription opioid overdose crisis and increased influx of illicitly manufactured fentanyl, fentanyl overdoses continue to be a public health crisis that has cost the US economy over $1 trillion in reduced productivity, health care, family assistance, criminal justice, and accounted for over 74,000 deaths in 2023. A recent demographic shift in the opioid crisis has led to a rise in overdose deaths among the Latinx population. Harm reduction interventions, including the use of naloxone and fentanyl test strips, have been shown to be effective measures at reducing the number of opioid overdose deaths. The aim of this scoping review is to summarize naloxone and fentanyl test strip interventions and public health policies targeted to Latinx communities.

Methods

PubMed, CINHAL, Web of Science, Embase, and PsycINFO research databases using the keywords “fentanyl,” “Latinx,” “Harm Reduction,” “Naloxone,” and “Fentanyl Test Strips'' to identify studies published between January 1, 2013 and December 31, 2023. Endnote and Covidence software were used to catalog and manage citations for review of studies. Subsequently, studies that met inclusion criteria were then summarized using resulting themes.

Results

Twenty-seven articles met the inclusion criteria and were further abstracted for the scoping review. Of these articles, 77.7% (n = 21) included a naloxone intervention, while only 11.1% (n = 3) included a fentanyl test strip intervention. Furthermore, 30.1% (n = 8) of these studies were Latinx targeted, and 7.7% (n = 2) of the studies were adapted for Latinx populations. Four themes, including an overall lack of knowledge and awareness, a lack of access to harm reduction or opioid overdose prevention resources, an overall lack of culturally adapted and/or targeted interventions, and restrictive and punitive policies that limit the effectiveness of protective factors were highlighted in this scoping review.

Conclusion

Limited published research exists on the use of emerging harm reduction behaviors, such as the use of naloxone and fentanyl test strips as community intervention strategies to prevent opioid overdose deaths. Even fewer publications exist on the targeting and cultural adaptation of harm reduction interventions responsive to Latinx communities, especially those using theoretical approaches or frameworks to support these interventions. Future research is needed to assess the unique needs of Latinx populations and to develop culturally responsive programs to prevent opioid-related overdose deaths among this population.

Introduction

Over the last decade, fentanyl overdoses in the United States have climbed to staggering proportions. In 2021, more people between the ages of 15–54 died from an opioid-related overdose than from COVID-19 [1]. In 2022, fentanyl, also known as “Dance Fever,” “Dragon’s Breath,” or “Tango and Cash,” resulted in the deaths of over 100,000 individuals in the United States [2]. The loss of life resulting from fentanyl and its analogs has reached such a devastating level that fentanyl-related overdoses have been propelled into a public health emergency and garnered prominence on the national political stage [3,4,5]. In the United States, the Drug Enforcement Agency (DEA) classifies fentanyl as a schedule II narcotic under the United States Controlled Substances Act of 1970. This classification is reserved for drugs that are considered high risk for both physical and psychological dependence and have a high capacity for both use disorder and misuse [6]. Due to the increased influx of illicitly manufactured fentanyl, the DEA has also identified China and Mexico as significant producers of illicitly manufactured fentanyl found in the United States [7,8,9]. As the opioid crisis in the United States continues, the need for increasing the effectiveness of overdose interventions, such as naloxone and fentanyl test strips (FTS) distribution and educational interventions will become critical in curtailing the effects of illicitly manufactured fentanyl.

Nationally, more than ten million people over the age of 12 are estimated to have engaged in opioid misuse over the past year [10,11,12,13]. Of these, over two million of those who misused opioids identify as Latinx/Hispanic (Here, Latinx is used as a gender-neutral term for self-identifying Latin individuals [13]. Overall, opioid overdose deaths have steadily increased throughout the nation, with the death rates among the Latinx population doubling between 1999 and 2017 [14, 15]. More specifically, the greatest increase in opioid-related deaths among this population is due to synthetic opioids, most notably fentanyl. Fentanyl is the most commonly involved opioid in unintentional overdose deaths among the Latinx population at 40.2% [16]. These fentanyl-related opioid overdose deaths have increased 617% over the past ten years [16].

Naloxone and FTS are considered effective overdose prevention interventions, resulting in their widespread use in public health and social service programs in states with supportive policies [13, 17]. Indeed, public health policies that aim to strengthen data collection, safer prescribing practices, stigma and harm reduction, treatment expansion, and criminal justice reform are critical areas of the public health spectrum that may serve to improve the effectiveness of interventions involving naloxone and FTS [18]. While policies such as Naloxone Access Laws, Naloxone Standing Orders, and Good Samaritan Laws have been developed and enacted to increase access to Naloxone and offer legal protection to bystanders who intervene in an overdose situation, not all states have enacted these harm reduction policies [19]. Harm reduction policies are currently composed of one or a combination of three major policies. These policies are Naloxone Access Laws, Naloxone Standing Order Laws, and Good Samaritan Laws. Naloxone Access Laws provide legal immunity provisions for individuals who prescribe, dispense, or administer naloxone [20]. Naloxone Standing Order Statutes authorize pharmacists to dispense naloxone under a standing prescription, eliminating the need for a patient-prescriber encounter [21]. Lastly, Good Samaritan Laws provide legal protection to bystanders in the event that they may need to intervene in an overdose incident. The purpose of this approach is to encourage people to help those experiencing an overdose without fear of legal liability [22]. While these statutes aim to expand access to naloxone and offer legal protections, some states, such as Texas, have yet to enact the Naloxone Standing Order or Good Samaritan statutes [23]. Limiting protections for and access to Latinx communities further decreases the likelihood of successfully reducing fentanyl-related overdose rates, especially among minority populations. Furthermore, as of 2020, all states have enacted Naloxone Access laws. However, only 33 states enacted Naloxone Access, Naloxone Standing Order, and Good Samaritan laws. Conversely, two states, Texas and Wyoming, have enacted only Naloxone Access Laws.

Understanding the planning, implementation, and evaluation of opioid-related harm reduction interventions responsive to the unique needs of the Latinx/Hispanic population in the United States is an area of emerging priority. The Latinx population is experiencing a time of significant population growth in the United States [24]. The US Latinx community grew to over 62.5 million people in 2021, representing a twenty-four percent increase in just eleven years [24]. This significant growth accounts for more than 52% of the population growth of the entire United States [24]. This population continues to face numerous health challenges due to a variety of structural, cultural, and social barriers to health services, as well as significant disparities in health outcomes ranging from HIV infections to type 2 diabetes, to opioid overdose deaths [25, 26]. These disparities are further exacerbated by social factors such as limited health insurance access and utilization, higher rates of medical distrust, and lower rates of medical adherence [27]. Cultural barriers to seeking care, including language barriers, legal status, stigma, and discrimination, are pervasive, significant, and impactful to these communities. Despite these barriers, there are opportunities for continued improvement in health outcomes due to facilitating and protective factors such as more positive attitudes and improving levels of trust towards health interventions [28,29,30,31,32].

Specifically related to opioid misuse, many fentanyl transportation routes traverse Latin America to the United States. This observation, in concert with cultural, economic, and social barriers, may contribute to an environment for the off-label use and sharing of both prescribed and illicit medications [16, 17]. These are only a few of the issues that result in the ongoing increases in unintentional opioid-related overdose deaths among Latinx populations [16]. As Latinx populations in the United States continue to grow, it is important to meet this population’s health and social needs.

Harm reduction strategies are proven to mitigate the number of unintentional opioid-related overdose deaths [33]. The harm reduction approach acknowledges abstinence as the ideal outcome but takes a person-centered strategy that seeks to mitigate risks through the provision of safer choice options [34]. Harm reduction approaches to mitigate the impact of opioid misuse and its associated health effects can include but are not limited to, the use of naloxone and the use of FTS [17, 35,36,37]. It is estimated that approximately 70% of unintentional opioid overdose deaths could be avoided through known harm reduction strategies [13]. Therefore, with the sharp increase in opioid-related deaths among Latinx populations, more understanding is needed to assess the viability of the implementation of harm reduction strategies and supportive policies for this at-risk population [13]. To this end, a literature review was conducted to describe interventions and policies used with Latinx populations.

Methods

Five established research databases (PubMed, Embase, PsycINFO, CINAHL, Web of Science) were used to search and compile available publications. The established inclusion criteria for the review were studies published between January 1, 2013 and December 31, 2023, studies published in the English language, and studies based in the United States or its territories. Both qualitative and quantitative studies that met the inclusion criteria were included for review. The scoping review was conducted utilizing the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines [38]. The University of Texas at Austin and University of Nevada, Reno library portals allowed for the electronic search of the databases for analysis. The search included a range of terms, including text words and amended vocabulary words, to elicit maximum results. The search terms included Latin*, Hispanic, fentanyl, naloxone, fentanyl overdose, fentanyl test strips, community readiness, overdose prevention, community readiness, opioid harm reduction, harm reduction, education, and outreach. These terms were combined with Boolean operators such as AND and OR for additional results.

Planned searches were queried using independent and sequential searches of the established strategy. The results were gathered as Research Information System (.ris) files, and these files were subsequently imported into the Covidence software system (Melbourne, Australia) for title, abstract screening, full-text screening, and data extraction. Covidence software was used to eliminate duplicate articles gathered from queries. Upon deduplication in Covidence, amended files were also imported into the Zotero or Endnote reference management software for ease of gathering full texts of included studies that were not automatically uploaded into Covidence and to create memos and notes of the reviewed articles.

Five established criteria were used to determine inclusion in the scoping review: (1) discussion of harm reduction strategies, such as distribution of naloxone or use of FTS; (2) inclusion of Latinx/Hispanic populations in the study; (3) health context of opioid use/misuse; (4) study published in English; (5) study occurred in the United States or its territories. Articles were excluded if they did not explicitly mention opioids or include reference to Latinx/Hispanic populations. A study must have met all five inclusion criteria in order for it to be considered for review.

Screening of titles and abstracts of de-duplicated results were conducted independently for each article by two authors (GL and GD) with initial discussion on operational definitions and inclusion criteria established prior to coding. Articles meeting initial screening criteria were moved to the second stage of full-text screening prior to data extraction. Any article accepted from the initial title and abstract screening from either coder (GL and GD) was included for a full-text screening. Following a full-text screening by the two authors, independent decisions by each author were discussed during a meeting that included the further refinement of operational definitions and inclusion criteria. Initial matched decisions after full-text review were moved into the data extraction phase. Those articles with unmatched decisions were discussed and reconciliation of coding decisions was established through a reassessment of the inclusion criteria. Resolved matches that met inclusion criteria were also moved to the data extraction phase. The authors took detailed notes of discussions and decision-making throughout the process.

Additional quality assessment was ensured through inter-rater reliability (IRR) calculations of the percentage of agreement and Cohen’s kappa prior to unmatched decision reconciliation and data extraction. The percentage of agreement was calculated at 97.3% (393/404), showing strong levels of agreement. As an additional measurement of reliability, Cohen’s kappa was calculated to assess the degree of IRR between the two coders that also account for chance. The Cohen’s kappa coefficient was calculated with a value of 0.761, indicating a substantial level of agreement.

A standard data extraction template was created using Covidence for those articles that met the abstract and full-text review phases of analysis. Within the data extraction template, several fields were collected, including (1) article details (authors, year of publication, title, journal); (2) study details (aim, study design, participant/sample characteristics); (3) Latinx/Hispanic details, such as percentage/total number of Latinx/Hispanic participants; whether the research was “Latinx/Hispanic targeted” which was defined as resources specifically designed to address the needs of Latinx and Hispanic communities who are disproportionately affected by fentanyl overdoses and/or “Latinx/Hispanic intervention adapted” that was defined as existing evidence-based interventions that were modified to better suit the needs and cultural context of the Latinx and Hispanic communities; (4) intervention characteristics (phase in intervention: coded as planning/assessment, implementation, or evaluation; type of intervention: coded as Narcan/naloxone and/or FTS or neither; theory/framework utilized: open-ended or coded as NA if none were applied); (6) study results (outcomes, recommendations, limitations). Using axial and open coding techniques, an iterative process was used to establish and stratify themes of outcomes and recommendations listed within the studies.

Results

The screening was conducted in a four-stage process using a documented search strategy (Fig. 1). The scoping review yielded a total of 823 studies that were imported for screening (Fig. 2). In stage 1 of the review process, 419 duplicates were identified by Covidence and were removed from further analysis, leaving 404 studies for review. In stage 2, 404 studies were screened through an abstract review process by the authors (GL and GD), matching the study abstracts to the inclusion criteria. Any studies that were unclear in meeting inclusion criteria were also included for full-text review to determine inclusion. In total, 337 studies were excluded from the stage 2 evaluation process review. In stage 3, 48 studies were subject to a full-text review. Twenty-one of the studies were excluded after a full-text review due to having an intervention or study design that did not meet the inclusion criteria. In total, 27 studies from 11 states and Puerto Rico were included for data abstraction (Fig. 3).

Fig. 1

Documented search strategy used in each of the five established research databases

Fig. 2

PRISMA diagram visualization of the identification, screening, and included studies using the documented search strategy

Fig. 3

Individual states and Puerto Rico with the number of studies that met the inclusion criteria for review

All 27 studies were empirical and met the inclusion criteria for data abstraction. Of the 27 studies, 73% (n = 19) explicitly included Narcan/naloxone, such as prescribed naloxone interventions, community-distributed interventions, peer-distributed interventions, or take-home naloxone interventions. Conversely, only 11.5% (n = 3) of studies focused on fentanyl test strip strategies that included both fentanyl strip interventions or a discussion of fentanyl test strips and drug checking services (DCS) more broadly. These results highlight the apparent underutilization of FTS compared to the more reactive interventions involving Narcan/naloxone among Latinx communities. A total of 30.1% (n = 8) of these studies explicitly studied or targeted the Latinx/Hispanic population through oversampling, researching an area with a large Latinx/Hispanic demographic, or including racial/ethnic comparisons with adequate sample sizes. Finally, 7.7% (n = 2) of the studies were adapted interventions for Latinx populations where the interventions included cultural adaptation, language adaptation, or the study design focused on assessments unique to the Latinx/Hispanic community (Table 1).

Table 1 Characteristics of included studies

When considering the phase of intervention in the lifecycle, 53.8% (n = 14) of the studies existed in the planning and assessment phase, which sometimes included a discussion of lived experiences with harm reduction interventions or an assessment of attitudes, norms, or beliefs related to harm reduction or opioid use in general. 19.2% (n = 5) of the included studies were in the intervention implementation phase, often through a pilot study or a description of a program enacted. Finally, 26.9% (n = 7) of the studies existed in the evaluation phase of the intervention lifecycle, which included an assessment of outcomes or program effectiveness.

In total, 11.5% (n = 3) of studies included some reference to a theory, framework, or behavior change model. One study was grounded in social networks theory [10]. Another used the information-motivation-behavior skills model of behavior change [11]. The third proposed a new theoretical framework of “unmet obligations” that was situated at the intersection of structural injustice, policy change, and critical race understandings [10, 11, 39].

Thematic analysis

Based on the analysis, four themes emerged from the studies: (1) an overall lack of knowledge and awareness of opioid use in general, Narcan/naloxone, FTS, and/or harm reduction strategies; (2) an overall lack of access to harm reduction or opioid overdose prevention resources; (3) an overall lack of culturally adapted and/or targeted interventions; (4) restrictive and punitive policies that limit protective factors (Table 2).

Table 2 Outcomes, recommendations, and limitations of included studies

The most prominent theme was that many members of the Latinx/Hispanic community are unaware of interventions, such as naloxone to prevent opioid overdose deaths, fentanyl test kits to test drugs, or harm reduction strategies in general [40]. Despite lower levels of health literacy related to harm reduction and opioid overdose awareness among all populations, Latinx audiences often demonstrated the least amount of knowledge [17]. The studies clearly showed a lack of outreach to Latinx communities for community education efforts [17].

Latinx individuals also had less access to harm reduction or opioid prevention resources when compared to White, non-Hispanics [41, 42]. Although closely related to a lack of knowledge and awareness, Latinx individuals were less likely to be prescribed naloxone by a medical provider [43, 44] and are also less likely to have access to drug-checking services and FTS than their White, non-Hispanic counterparts [37, 45]. When having access to opioid overdose prevention resources, Latinx populations had greater odds of using the naloxone they bring home [28, 46,47,48] and were more likely to refill the prescription for naloxone [49, 50]. Finally, after a known fentanyl exposure, Latinx community members are more likely to adopt harm-reduction behaviors [51].

Another theme that emerged is an overall lack of culturally responsive education and intervention programs specifically targeted to Latinx communities. Although interventions exist, the lack of cultural adaptation prevents their overall uptake [52, 53]. Latinx communities are responsive to harm reduction strategies adapted to their culture and language and have shown a willingness to receive education and resources in various formats, including virtually or through the utilization of community health workers [49, 54,55,56]. However, cultural factors, experiences, restrictive policies, including the war on drugs, and drug paraphernalia laws, impede the inability to distribute naloxone or FTS legally, restrictions on pharmacist-led standing orders on naloxone, and restrictions on peer-based naloxone distribution, further marginalize Latinx communities (Fig. 4). Due to interactions with immigration, discrimination, or stigma, Latinx communities can be more cautious in adopting opioid overdose prevention strategies when residing in communities with restrictive policies [28, 36, 54, 56,57,58].

Fig. 4

States with and without Naloxone Access Laws, Naloxone Standing Order Laws, and Good Samaritan Laws

Punitive and restrictive policies related to naloxone and FTS was also a prominent theme throughout this scoping review. Indeed, in Pennsylvania, a lack of supportive policies showed that Latinos were shown to be more likely to be arrested in cases where naloxone was administered compared to Whites and Blacks [59]. Harm reduction studies also advocated for policy changes to allow for increasing the ease of access to naloxone, FTS, and other drug-checking services [36, 56]. In order to advance overdose prevention interventions, one study suggested increasing the inclusion of Black and Latinx individuals in positions of policy leadership to better meet the needs of diverse populations [58]. While major legislative policies aim to increase ease of access to harm reduction strategies, additional work is needed to improve upon the underutilization of these interventions.

Discussion

This scoping review displays the ongoing need for the planning, assessment, implementation, and evaluation of key opioid overdose prevention strategies such as naloxone distribution and the widespread use of FTS, especially among Latinx populations. Overall, the results indicate that more education and outreach are needed on harm reduction strategies, especially strategies that provide choice, options, and innovative solutions. Expanding education efforts related to harm reduction policies among Latinx communities about naloxone and FTS distribution sites, use, and legal protections may present areas of opportunity to increase the utilization of harm reduction measures among the Latinx population. The scoping review highlights a few innovative interventions, such as virtual, culturally responsive training and peer outreach through the use of trained community health workers [43, 54]. Latinx individuals are more open to harm reduction interventions than non-Hispanic Whites but less likely to receive the opioid overdose prevention resources they need to protect themselves and their communities [36, 43].

The needs and resources of the Latinx community present a unique opportunity for intervention. While sources of naloxone distribution encompass a wide array of sites such as emergency departments [60, 61], syringe service programs [62], pharmacies [63], community peer-based interventions [64], opioid agonist treatment services, among others, these distribution methods often lack a cultural framework amenable to acceptance with the Latinx community. Additionally, the distribution of rapid FTS in these settings may provide an added measure of protection, as FTS has been shown to be a more acceptable form of harm reduction, especially among young adults [65, 66]. Culturally, barriers such as cultural norms to buy medication outside of a medical setting or to share medications can put Latinx community members at undue risk of potential opioid overdose death [17]. Socially, restrictive policies preventing access to harm reduction resources, coupled with structural and systemic barriers of past discrimination and stigma within the healthcare system and among law enforcement, created an ongoing threat to optimal health and safety [35, 36, 56]. Restrictive and punitive policy implications may result in limiting the utilization of evidence-based harm reduction measures, increasing fentanyl-related overdose deaths, or increasing stigma, leading at-risk individuals away from seeking help, especially among Latinx individuals. Punitive policies that classify drug checking material, such as FTS, as paraphernalia may serve to further deter members of the Latinx community from utilizing these harm reduction measures. Indeed, efforts in many states’ legislative bodies are underway to remove FTS from being classified as drug paraphernalia. Currently, 32 states still consider “testing equipment for the use in identifying, or in analyzing the strength, effectiveness or purity of controlled substances'' as drug paraphernalia and are therefore outlawed [19].

Yet, culturally relevant opportunities for change also exist, including core Latinx norms of a collectivist culture, a focus on the family, and extended social networks that can serve as protective factors associated with increased use of opioid overdose prevention resources and decreased deaths among this population [10, 47, 55]. More targeted, culturally responsive, and adapted interventions are needed that directly meet the needs of Latinx populations. Examples of such interventions may include increasing language accessibility, incorporating family-centered approaches, religious or spiritual integration, or reducing stigma. Overall, the scoping review elucidated the need for additional interventions in all stages of the intervention lifecycle that are grounded in proven theories and frameworks that may be increasingly impactful to Latinx populations in reducing unintentional opioid overdose deaths.

Conclusion

While reactive interventions involving naloxone continue to expand overall, prophylactic measures such as FTS remain underutilized among Latinx communities. Increasing awareness and access while addressing barriers to accessing FTS may contribute to reducing the number of unintentional fentanyl-related overdose deaths. The Latinx population may also be subjected to additional barriers in accessing FTS. These may include a lack of knowledge, fear of deportation, language barriers, cultural stigma, and financial considerations [17]. Furthermore, many Latinx individuals are unaware of the existence of FTS or do not know how to use them. This may be particularly relevant in rural areas or communities with historically limited access to healthcare resources. Surprisingly, researchers have highlighted a paradoxical phenomenon among Latinx communities, indicating that Latinx individuals may be protected from the prescription opioid crisis as a result of their inability to access care, but this observation does not appear to confer protective effects with respect to obtaining illegal drugs [67].

This scoping review of opioid overdose prevention interventions to promote the use of naloxone and FTS highlights the willingness of Latinx community members to adopt harm reduction strategies. However, limited opportunities for education, outreach, and the provision of resources are available. Interventions that are culturally adapted and responsive are limited, lack theoretical foundations, and are not implemented at scale. Although threats related to the cultural norms of the Latinx community exist, there are also unique opportunities to build upon these cultural norms that can serve as protective factors to achieve optimal health. Moreover, this scoping review highlights the need for future research in the development, implementation, and evaluation of evidence-based, culturally responsive programs to meet the needs of Latinx populations in combating opioid overdose deaths within their communities.