Naloxone and the overdose death epidemic
For the 12-month period ending in May 2021, the United States (U.S.) reported 97,516 overdose deaths, the majority of which involved opioids [1]. One important component of a comprehensive national response to the overdose death epidemic is education on and distribution of naloxone [2], an opioid receptor antagonist that is used to reverse the effects of opioids, thereby preventing overdose death [3]. Research studies and expert analysis consistently have affirmed the value of naloxone availability and training as an overdose mitigation approach [4,5,6,7].
Attitudes toward expanded naloxone access
Some researchers recently have expressed concern that misinformation about naloxone may hamper its distribution or use [8]. However, the nature and prevalence of such misinformation in the U.S. remains unclear, and studies thereof often are intermixed with broader concepts of support for or objection to expanded access. A 2010 summary of objections to take-home naloxone [9] highlighted both policy-level opposition from the early 2000s and instances of controversy in the news media regarding access or rumors about naloxone. Examples of the latter [10, 11] have continued to appear intermittently in national and local media in the past decade.
A few papers have examined lay support for naloxone access (or, conversely, opposition thereto). One study found associations between Just World Belief (“people getting what they deserve and deserving what they get”), individualism, and concern about naloxone access expansion [12]. Another survey found correlations between opposition to nonprescription naloxone and a variety of factors including social dominance orientation (support for inequality between different groups), endorsing authoritarian ideas, and perceiving that opioid users present a threat to the nation [13]. At the same time, support in those studies for take-home naloxone was relatively high. In a different study examining layperson perception of community pharmacist dispensing of naloxone, roughly 2/3 of respondents were comfortable with such an approach, but those who were not often cited “promoting drug abuse and misuse” or “promoting reckless behavior” as reasons for discomfort [14]. Similar concerns have been elicited from law enforcement officers, more than 80% of whom in one recent study indicated that naloxone “gives people who use drugs an excuse to continue doing drugs,” though many respondents also indicated willingness and ability to use naloxone and interface with drug treatment programs [15].
Though such studies provide helpful context, we do not currently have a clear sense of the ways in which laypersons think about overdose and naloxone, nor do we know the prevalence of such beliefs or whether they co-occur. At the same time, despite proliferation of state-level support for naloxone distribution (e.g., third-party prescribing) [16], the combination of anecdotal examples in the news and other studies permits inference that at least some people hold beliefs about overdose and naloxone that either do not correspond with existing scientific evidence or are misinformed.
Characterizing layperson beliefs about overdose and naloxone
To better understand layperson beliefs, we designed a study to examine how believable a national sample of respondents found statements about naloxone and overdose to be. The study examined beliefs across four conceptual domains.
The first domain was risk compensation beliefs – the idea that people who use opioids will use more opioids or be less likely to seek treatment if they have access to naloxone [17]. While there may be anecdotal exceptions, such beliefs do not align with extant evidence about population-level effects, which fairly strongly indicates that naloxone education and distribution are not associated with increased opioid use [18,19,20,21] or reduced risk perceptions for heroin use [22].
The second domain was beliefs about overdose inevitability – the idea that people who experience nonfatal overdose once will usually overdose again and will usually die of an overdose within the year. Here, we emphasize our inclusion of the term usually as a normative claim about the most likely outcome. In contrast to such beliefs, current evidence indicates that while risk of mortality and morbidity is substantively elevated following a nonfatal overdose, the preponderance of that risk is not attributable to a subsequent overdose (fatal or nonfatal), though subsequent overdoses can and do occur in a percentage of people, and an index overdose is a significant risk factor for a repeated overdose [23,24,25,26]. Risk of a repeated overdose also appears to be higher among those with diagnoses of anxiety, depression, or substance use disorders prior to overdose [27].
The third domain was believability of misinformation – in this case, the idea that take-home naloxone can be used to get high, which is not possible [3]. Finally, the fourth domain was related to the efficacy of layperson naloxone – the idea that training and provision of naloxone is associated with bystander prevention of community overdose. Research suggests that layperson naloxone training and distribution is feasible [28], and a large-scale observation study found that it was associated with reduced community deaths from overdose [29].
Our approach to understanding these beliefs was informed by our prior work on beliefs about COVID-19 [30, 31]. There, we found that reported believability of statements about COVID-19 clustered. There was a latent group of people that found a scientifically supported statement to be believable while finding misinformed or unsupported narratives to be unbelievable, and several groups that reported believing narratives that were either misinformed or unlikely to be true, while also not rejecting a scientifically supported statement. We hypothesized that beliefs about naloxone and overdose might cluster similarly. Further, trust in science was very strongly associated with COVID-19 belief profiles, but it was less clear whether that would be the case for naloxone and overdose, or whether other factors, such as knowledge and prior experiences, would offer more explanatory power.
Considering all these factors, we believe that examining beliefs about naloxone and overdose in a rigorous manner can potentially support important research and policy initiatives. Thus, this study tested three preregistered hypotheses (1, 2, and 2a) and one exploratory aim (3), included here verbatim: [32].
Study hypotheses
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1) There will be some prevalence of [unsupported beliefs] about naloxone; however, we are agnostic as to the degree of prevalence, except that it will be non-zero.
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2) Latent profile analysis (LPA) of beliefs about naloxone, using the prespecified criteria to determine the number of profiles, will identify at least two latent profiles of study participants.
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3) We will conduct an exploratory multivariate regression model to contrast each of the latent profiles. All variables indicated in the "Variables" section will be included in the model. Significance testing will be two-sided and contrast odds compared to the most populated latent profile.