Does naloxone provision lead to increased substance use? A systematic review to assess if there is evidence of a ‘moral hazard’ associated with naloxone supply

Tse, Wai Chung; Djordjevic, Filip; Borja, Viandro A.; Lam, Tina; Olsen, Anna; Larney, Sarah; Dietze, Paul; Nielsen, Suzanne

doi:10.1016/j.drugpo.2021.103513

Cited by 33 publications

(47 citation statements)

References 40 publications

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“…Experts also generally believed that increased naloxone availability does not have appreciable negative impacts on the prevalence of opioid misuse, OUD, and non-fatal opioid overdoses. This contrasts with recent work suggesting increasing rates of both nonfatal opioid-related overdoses and opioid-related crime following standing order or third-party prescribing laws [ 48 ], but aligns with several studies showing no evidence that take-home naloxone provision promotes increased opioid use or overdose [ 49 ]. Additionally, while experts expect any short-term mechanical increases in OUD or non-fatal overdoses to be small, many do not think they are negligible or insignificant (i.e., policymakers should consider and plan for them).…”

Section: Discussioncontrasting

confidence: 60%

Expert views on state-level naloxone access laws: a qualitative analysis of an online modified-Delphi process

Grant

Smart

2022

Harm Reduct J

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Background Expanding availability to naloxone is a core harm reduction strategy in efforts to address the opioid epidemic. In the US, state-level legislation is a prominent mechanism to expand naloxone availability through various venues, such as community pharmacies. This qualitative study aimed to identify and summarize the views of experts on state-level naloxone access laws. Methods We conducted a three-round modified-Delphi process using the online ExpertLens platform. Participants included 46 key stakeholders representing various groups (advocates, healthcare providers, human/social service practitioners, policymakers, and researchers) with expertise naloxone access laws. Participants commented on the effectiveness and implementability of 15 state-level naloxone access laws (NALs). We thematically analyzed participant comments to summarize views on NALs overall and specific types of NAL. Results Participants commented that the effectiveness of NALs in reducing opioid-related mortality depends on their ability to make sustained, significant impacts on population-level naloxone availability. Participants generally believed that increased naloxone availability does not have appreciable negative impacts on the prevalence of opioid misuse, opioid use disorder (OUD), and non-fatal opioid overdoses. Implementation barriers include stigma among the general public, affordability of naloxone, and reliance on an inequitable healthcare system. Conclusions Experts believe NALs that significantly increase naloxone access are associated with less overdose mortality without risking substantial unintended public health outcomes. To maximize impacts, high-value NALs should explicitly counter existing healthcare system inequities, address stigmatization of opioid use and naloxone, maintain reasonable prices for purchasing naloxone, and target settings beyond community pharmacies to distribute naloxone.

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Section: Discussioncontrasting

confidence: 60%

Expert views on state-level naloxone access laws: a qualitative analysis of an online modified-Delphi process

Grant

Smart

2022

Harm Reduct J

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“…In the case of naloxone, a substantial public debate emerged over a study of the ‘moral hazard’ of naloxone [ 46 ]. The 2018 pre-print igniting the debate has been mentioned in 60 news articles (though sometimes for tangential topics, like face masks for COVID-19) and 1,503 tweets [ 47 ], whereas a systematic review with different conclusions, published November 2021, has not yet been mentioned in any news media captured by PlumX, and has been mentioned in 164 tweets [ 21 ].…”

Section: Discussionmentioning

confidence: 99%

“…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 – 21 ] or reduced risk perceptions for heroin use [ 22 ].…”

Section: Introductionmentioning

confidence: 99%

Beliefs and misperceptions about naloxone and overdose among U.S. laypersons: a cross-sectional study

2022

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Background Overdose education and naloxone distribution (OEND) to laypersons are key approaches to reduce the incidence of opioid-involved overdoses. While some research has examined attitudes toward OEND, especially among pharmacists and first responders, our understanding of what laypersons believe about overdose and naloxone is surprisingly limited. Further, some scholars have expressed concerns about the prevalence of non-evidence-based beliefs about overdose and naloxone. We designed this study to analyze the prevalence, nature, and context of beliefs about naloxone and overdose among U.S. laypersons. Methods We conducted a cross-sectional study (n = 702) using Prolific.co (representative of the U.S. population by age, gender, and race). Primary outcomes were the believability of six statements about overdose/naloxone on a seven-point Likert-type scale. Five statements were unsupported, and one was supported, by current scientific evidence. We used latent profile analysis to classify participants into belief groups, then used regression to study correlates of profile classification. Results Believability of the statements (7: extremely believable) ranged from m = 5.57 (SD = 1.38) for a scientifically supported idea (trained bystanders can reverse overdose with naloxone), to m = 3.33 (SD = 1.83) for a statement claiming opioid users can get high on naloxone. Participants were classified into three latent belief profiles: Profile 1 (most aligned with current evidence; n = 246), Profile 2 (moderately aligned; n = 351), and Profile 3 (least aligned, n = 105). Compared to Profile 1, several covariates were associated with categorization into Profiles 2 and 3, including lower trust in science (RRR = 0.36, 95%CI = 0.24–0.54; RRR = 0.21, 95%CI = 0.12–0.36, respectively), conservative political orientation (RRR = 1.41, 95%CI = 1.23–1.63; 3:RRR = 1.62, 95%CI = 1.35–1.95, respectively), and never being trained about naloxone (Profile 3: RRR = 3.37, 95%CI = 1.16–9.77). Conclusions Preliminary evidence suggests some U.S. laypersons simultaneously believe that bystander overdose prevention with naloxone can prevent overdose and one or more scientifically unsupported claims about naloxone/overdose. Categorization into clusters displaying such belief patterns was associated with low trust in science, conservative political orientation, and not having been trained about naloxone. Preregistration This cross-sectional study was preregistered prior to any data collection using the Open Science Framework: https://osf.io/c6ufv

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“…There is a growing evidence base for the positive impact of THN on reducing drug deaths [ 9 , 10 ]. A recent systematic review from Australia refuted misconceptions that THN would lead to increased substance use, finding instead that it ‘has a net benefit in terms of drug use behaviours’ [ 11 ].…”

Section: Introductionmentioning

confidence: 99%

‘I’m not going to leave someone to die’: carriage of naloxone by police in Scotland within a public health framework: a qualitative study of acceptability and experiences

et al. 2023

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Background Scotland has one of the highest rates of drug-related deaths (DRDs) per capita in Europe, the majority of which involve opioids. Naloxone is a medication used to reverse opioid-related overdoses. In efforts to tackle escalating DRDs in many countries, naloxone is increasingly being provided to people who are likely first responders in overdose situations. This includes non-healthcare professionals, such as police officers. A pilot exercise to test the carriage and administration of naloxone by police officers was conducted in selected areas of Scotland between March and October 2021. The aim of the study was to explore the acceptability and experiences of naloxone carriage and administration by police in Scotland. Methods The study comprised of two stages. Stage 1 involved in-depth one-to-one qualitative interviews with 19 community stakeholders (people with lived experience, family members, support workers). Stage 2 involved a mixture of in-depth one-to-one interviews and focus groups with 41 police officers. Data were analysed thematically, and the findings from the two stages were triangulated to develop overarching themes and subthemes. Results By the end of the pilot, 808 police officers had been trained in the use of intranasal naloxone. Voluntary uptake of naloxone kits among police officers who completed training was 81%. There were 51 naloxone administration incidents recorded by police officers at suspected opioid-related overdose incidents during the pilot. Most officers shared positive experiences of naloxone administration. Naloxone as a first aid tool suited their role as first responders and their duty and desire to preserve life. Perceived barriers included concerns about police undertaking health-related work, potential legal liabilities and stigmatising attitudes. The majority of participants (and all community stakeholders) were supportive of the pilot and for it to be expanded across Scotland. Conclusions Police carriage of naloxone is an acceptable and potentially valuable harm reduction tool to help tackle the DRDs crisis in Scotland. However, it requires appropriate integration with existing health and social care systems. The intervention lies at the intersection between public health and policing and implies a more explicit public health approach to policing.

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Does naloxone provision lead to increased substance use? A systematic review to assess if there is evidence of a ‘moral hazard’ associated with naloxone supply

Cited by 33 publications

References 40 publications

Expert views on state-level naloxone access laws: a qualitative analysis of an online modified-Delphi process

Expert views on state-level naloxone access laws: a qualitative analysis of an online modified-Delphi process

Beliefs and misperceptions about naloxone and overdose among U.S. laypersons: a cross-sectional study

‘I’m not going to leave someone to die’: carriage of naloxone by police in Scotland within a public health framework: a qualitative study of acceptability and experiences

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