Naloxone education & distribution programs

There is strong evidence that opioid overdose education and naloxone distribution programs increase knowledge of appropriate overdose response among participants with substance use disorders and other participants who are likely to encounter an overdose situation (Jones 2022b, Rawal 2023, Razaghizad 2021, Winhusen 2020, Clark 2014, Giglio 2015, Lewis 2016, Ashrafioun 2016, Lott 2016). Naloxone distribution through such programs is associated with reduced opioid overdose deaths (Razaghizad 2021, Chimbar 2018, Giglio 2015, Walley 2013), increased opioid overdose reversal (Rawal 2023), and increased self-confidence in participants’ ability to respond effectively to overdoses (Razaghizad 2021, Ashrafioun 2016, Wagner 2016, Strang 2008). Education for pharmacists and primary care providers appears to have positive effects on Naloxone prescribing and dispensing rates, while also decreasing opioid drug prescribing over time (Kulbokas 2021).

Communities that implement programs to train potential bystanders (e.g., social service staff, individuals with a substance use disorder, and their family and friends) to identify an opioid overdose and respond with naloxone appear to reduce opioid overdose death rates more than communities that do not implement such programs (Walley 2013). In New York, community members attending Opioid Overdose Education and Naloxone Distribution (OEND) training programs improved their knowledge and attitudes about opioid overdose (Heavey 2018). Family and friends of individuals with a substance use disorder have greater knowledge of opioid overdose and ability to respond appropriately after receiving training in naloxone administration than peers who learn about opioid overdose and naloxone via an information booklet (Williams 2014). Some studies suggest individuals with a substance use disorder who participate in a brief 5-10 minute training or learn naloxone administration through social networks can respond appropriately to an overdose (Doe-Simkins 2014, Behar 2014).

Opioid overdose education delivered via computer or written pamphlets can increase knowledge and reduce behavioral risk factors (Sisson 2023, Dunn 2017, Berland 2019). Personalized computer-based OEND programs have been shown to decrease perceived treatment barriers and self-reported opioid use among individuals with a substance use disorder (Winhusen 2020). OEND program participation may increase adherence to medications that treat opioid use disorder (Jones 2021a). Participants in extended training programs are more likely to use naloxone in the short term; however, no difference in naloxone use remains one year after participation in either type of training (Jones 2022b).

Training first responders such as police, firefighters, and EMTs to administer naloxone may reduce time to overdose rescue, possibly decreasing overdose-related injury and death (Davis 2014c). Law enforcement officers and pharmacy students who participate in naloxone administration and overdose training report increases in knowledge and confidence in managing opioid overdose emergencies after program completion (Kwon 2020, Dahlem 2023, White 2021, Dahlem 2017, Purviance 2017, Wagner 2016). Implementing naloxone distribution programs within emergency department settings may increase access to naloxone among high-risk populations (Gunn 2018); however, allocating training time within already overloaded schedules for emergency department staff can be challenging (Gunn 2018). Prescribing of naloxone by primary care providers may be a way to expand access to individuals who are not part of a community-based approach (Behar 2018). Take home naloxone programs do not seem to increase opioid or substance use (Tse 2022, Katzman 2020, Chimbar 2018).

Naloxone services provided by pharmacists are beneficial beyond community pharmacy settings and should be considered to create more targeted future programs (e.g., for veterans affairs and academic medical centers) (Rawal 2023). Many pharmacists are knowledgeable and confident dispensing naloxone; however, one Ohio-based survey suggests barriers remain in understanding local and state laws (Thompson 2019). Additional barriers among pharmacists include education and training, workflow, and management support (Thakur 2019, Muzyk 2019). Among medical students, both online and in-person overdose trainings have been shown to be effective (Berland 2019, Berland 2017). Trainings on overdose response and naloxone administration can be incorporated broadly in current medical school curriculum (Taylor 2018) or specifically for pharmacy students (Kwon 2020). Input and perspectives from people who use drugs should be included when designing overdose education and naloxone distribution programs to improve program reach and effectiveness (Enich 2023).

Community-based naloxone distribution programs are cost-effective (Resko 2024, Cherrier 2022). U.S.-based and international analyses estimate that naloxone programs have large positive benefits for society, ranging from hundreds to tens of thousands of dollars (Cherrier 2022). Overdose education and naloxone distribution operating costs vary by program type and number of sites (Behrends 2022).

Naloxone education and distribution programs have the potential to decrease disparities in naloxone distribution and access to reduce overdose deaths. Inequalities by race, geographic location, and economic status persist in overdose deaths (CDC-Disparities widen, Zhang 2018c). Most people who overdose are non-Hispanic whites, about 10% are non-Hispanic Blacks, and 8% are Hispanic (Salmond 2019). Experts attribute this demographic breakdown to the unconscious bias and prejudices of health care providers, who are more cautious prescribing opioids to non-white patients based on the prejudiced assumption that non-white patients are more likely to abuse or sell opioid prescription drugs (Salmond 2019). Individuals who exhibit mental health conditions are also more likely to use opioids (Salmond 2019). Providing naloxone and related education to family members of individuals with opioid use disorders is a cost-effective approach to increase access to naloxone for high-risk individuals. There is a need to reach family members of minoritized racial groups as attitudes among this group are more negative toward overdose response compared to their white counterparts (Resko 2024).

In the United States, opioid-related overdose death rates are much higher in rural areas compared to urban areas (Zhang 2018c). Administration of naloxone by life support personnel is low, even in areas with high overdose death rates. Policies that expand naloxone administration by EMTs and increase access for those at risk of overdose may reduce opioid-related overdose deaths in rural areas (Zhang 2018c). A study conducted in Massachusetts and Rhode Island found that areas encompassing large cities have higher naloxone kit distribution rates per opioid overdose deaths compared to non-urban areas that don’t encompass large cities (Zang 2021).

Adults who experience homelessness are disproportionately impacted by opioid overdoses and can benefit from naloxone education and distribution programs. An opioid overdose training and routine naloxone prescribing program at a homeless clinic in Pennsylvania, found that patients significantly increased their knowledge of opiate overdose after participating in the 15-minute education program. More research is needed to understand the barriers around naloxone fill rates, including housing, insurance, and other prescription use status (Pietrusza 2018). Opioid overdose rates are highest among individuals with less education and fewer employment opportunities (Judd 2023).

Opioid overdose deaths have been increasing since 1999 (Freeman 2018). The rise in opioid overdose deaths began in the 1990s with a substantial increase in the prescription of both natural and semi-synthetic opioids because they were effective at managing chronic pain and falsely marketed to health care providers as non-addictive (CDC-Understanding the epidemic, Bennett 2021, Haffajee 2020). Prescription opioid sales increased fourfold between 1999 and 2008 (Judd 2023). Many patients who became addicted to prescribed opioids turned to non-prescribed forms of opioids, such as heroin, which lead to a second wave of opioid overdoses in 2010. In 2013, a third wave began when synthetic opioids, such as fentanyl, that are much more potent than other forms of opioids were combined with other drugs or counterfeit prescription pills, often unknown to the purchaser (CDC-Understanding the epidemic). In 2013, the U.S. Department of Health and Human Services declared the misuse of prescription opioids an epidemic. Four years later, in 2017 the opioid epidemic was declared a national public health emergency (Salmond 2019). Between 2020 and 2021, the opioid overdose death rate increased by over 15% and the synthetic opioid overdose death rate increased by over 22% (CDC-Understanding the epidemic).

The dramatic increase in opioid sales was the result of pharmaceutical companies that overproduced and oversupplied opioid drugs for huge profits, pharmacies that filled the prescriptions, and health care providers who overprescribed the medications (Judd 2023). In rural areas many physicians overprescribed opioids to patients who travel long distances for treatment, do not have the ability to attend frequent appointments, and do not have alternative pain management interventions in their area (Judd 2023).

Naloxone was first approved by the FDA in 1971; however, its use was primarily limited to hospitals or ambulances and was controlled by those in the health care and criminal justice systems. Despite the rise in medical prescription opioids often targeted at vulnerable populations, stigmatization of people who misuse opioids increased opposition to naloxone access and increased political, legal, financial, and logistical struggles faced by advocates for naloxone expansion (Bennett 2021). For decades advocates worked to overcome barriers to naloxone access and to reframe society’s response to drug use from a criminal justice-oriented approach to a public health approach. This narrative shift initially began to take effect as U.S. veterans struggled with opioid addiction while trying to manage chronic pain and as opioid use impacted many predominantly white, middle-class communities (Bennett 2021). The narrative shift has benefitted many white communities; however, predominantly Black and Hispanic communities are largely still treated with criminal justice-oriented policies and mindsets. By 2017, all 50 states in the U.S. have adopted some variation of naloxone access laws; however, more work needs to be done to address disparities in access and to continue to overcome stigma (Bennett 2021).

• How does your community provide naloxone education and support naloxone distribution? Are naloxone take home kits readily available for community members? If not, why is that?
• Who can you partner with to create or expand a naloxone education and distribution program in your community?
• What do opioid related overdose death rates look like in your community? Who has access to naloxone and who still needs access? What changes can your community make to a naloxone education and distribution program to reach community members at high risk of opioid overdose?

As of September 2019, there are 17 states that have enacted naloxone co-prescribing laws that allow prescribers to prescribe naloxone to patients who meet overdose risk criteria (Haffajee 2020). In 2014, 644 local opioid overdose prevention programs in 30 states and Washington, D.C. provided community members with naloxone kits and training in proper use (CDC MMWR-Naloxone 2015). Many states provide civil and criminal immunity for both prescribers and administrators (PDAPS-Naloxone, Davis 2015). The Veterans Health Administration (VHA) has developed and implemented a national Opioid Overdose Education and Naloxone Distribution (OEND) at all VHA medical facilities (Oliva 2017).

Since November 2017, all 50 states have passed and implemented enhanced naloxone access laws with only 19 of those states mandating naloxone education training to pharmacists before they engage in independent naloxone dispensing and prescribing activities (Roberts 2019).

In November 2015, a nasal spray method of administering naloxone was approved by the U.S. Food and Drug Administration (FDA) along with the previously-approved injection method (US FDA-Naloxone 2015).

Take home naloxone (THN) kits are increasingly available through community pharmacy-based THN programs (Cid 2021).

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