(111) People Can Recover: Qualitative Findings from a Statewide Naloxone Distribution Project

Background & Introduction: Naloxone, including nasal and injectable formulations, is a life-saving intervention that helps reverse opioid overdoses. It plays a critical role in mitigating the harms of the ongoing opioid crisis (1). To increase naloxone availability, many states have launched naloxone distribution initiatives (2). In 2021, one Midwest state implemented a program that provided free Narcan (nasal naloxone) through an online portal to organizations that register with the state. Organizations include harm reduction agencies, non-profit community organizations, substance use disorder treatment programs, medical and public health facilities, and criminal justice institutions. To receive Narcan through the program, organizations place orders via the online portal, and a state representative coordinates the ordering and shipping logistics with the Narcan distributor, who ships the Narcan directly to the organization. These organizations then distribute the Narcan widely in the community, providing it directly to individuals (i.e., people who use drugs, first responders, family members, other bystanders), as well as to other organizations (e.g., faith-based groups, businesses, educational institutions) for further distribution. Our team conducted a qualitative evaluation of this Narcan distribution program, aiming to examine: 1) implementation facilitators and challenges, 2) the impacts of the program on Narcan distribution and use, and 3) the program's sustainability.

Methods: We conducted 15 hour-long Zoom interviews between June and August 2024 with policymakers and implementation partners (N=4) and representatives from programs that ordered Narcan through the online portal (N=11) using a purposive sampling approach. To identify candidates for outreach, we solicited recommendations of policymakers and implementation partners from state program leadership and referenced a list of the 21 programs with the highest number of all-time Narcan orders through the program to identify participating organizations. We considered factors such as Narcan order volume, geographic diversity, and organization type, aiming to recruit representatives from a diverse range of participating organizations. This process resulted in a list of 26 candidates for outreach, and email outreach began in June 2024. The semi-structured interview protocol explored successful aspects of implementation, challenges related to ordering and distributing Narcan in communities, potential outcomes of the project, and the sustainability of naloxone distribution efforts. All interviews were recorded, transcribed, and coded using Dedoose qualitative software. Three staff members participated in coding, utilizing an interrater reliability (IRR) test through Dedoose to ensure alignment in coding. Using an applied thematic analysis approach, we identified common themes and synthesized the findings (3).

Results: We identified nine primary themes in the data, including: 1) improved resource allocation, 2) enhanced ordering efficiency, 3) increased trust and predictability, 4) stigma reduction, 5) expanded access, 6) institutional barriers, 7) data collection challenges, 8) impact on overdose fatalities, and 9) future considerations for sustainability.
The program allowed organizations to reallocate funds to other harm reduction supplies (e.g., fentanyl test strips) and increase staffing for distribution, resulting in broader distribution overall. Additionally, the user-friendly online portal streamlined the ordering and receiving of Narcan, enabling organizations to respond more quickly to emerging overdose trends. The ample, reliable supply of Narcan offered predictability for community members, fostering greater trust between individuals and service providers. Participants also praised the program for making significant progress in reducing stigma and increasing awareness and acceptance of Narcan.
By making Narcan available to organizations that had not previously supplied or distributed it—such as businesses (e.g., restaurants/bars, gas stations, clothing stores), religious institutions, schools, and universities—the program expanded Narcan access across various community sectors that may not have otherwise had it. However, many of these organizations faced institutional policies that created barriers to Narcan distribution, particularly in educational, criminal justice, and healthcare settings. Participants reported that leadership within these organizations was often reluctant to carry and distribute Narcan due to stigma, lack of awareness, and/or logistical challenges.
Organizations also encountered challenges in collecting data on Narcan use, particularly during high-stress situations and when anonymity was prioritized. These difficulties likely complicated efforts to measure the program's effectiveness and contributed to administrative and reporting burdens for participating organizations. Despite these data collection challenges, participants noted that anecdotal evidence and observed trends in overdose statistics strongly suggest that this Narcan distribution program has significantly contributed to reducing fatalities statewide. As one participant said, increasing access to Narcan “has a direct correlation with more people surviving. At the end of the day, that's what this is all about. Because people do recover. People can recover. They just need to be given the chance to do it… To me, in a nutshell, that is what this program is doing.”
Lastly, most participants believed that in the future, intramuscular naloxone should be offered through the program, in addition to the nasal formulation. Given that injectable naloxone is less expensive, offering it could provide a more sustainable option for continued naloxone distribution efforts.

Conclusion & Discussion: In conclusion, this Midwest state program increased the distribution of a life-saving intervention for opioid overdoses, offering individuals an opportunity to recover and seek further help. These findings underscore the importance of continuing state initiatives to support low-barrier or free access to evidence-based opioid use disorder interventions. Although measuring effectiveness is difficult, anecdotal evidence and trends in overdose statistics strongly suggest this Midwest state program has helped reduce fatalities. While the program helped expand Narcan access to community sectors previously without it, further work is needed to remove institutional barriers to distribution, especially in educational, criminal justice, and healthcare settings. Identifying trusted messengers (e.g., supportive school nurses, sheriffs, or emergency room doctors) could help promote Narcan distribution and address concerns with organizational leadership. Additionally, given the challenges organizations face in reporting actual Narcan use, innovative data collection methods, such as wastewater analysis (4), should be explored to better assess the impact of naloxone distribution efforts on overdose deaths. Ongoing funding for naloxone distribution is crucial to addressing the overdose crisis, and ensuring its sustainability—potentially through both injectable and nasal formulations—will be essential moving forward.

References: 1. Rao, I. J., Humphreys, K., & Brandeau, M. L. (2021). Effectiveness of policies for addressing the US opioid epidemic: a model-based analysis from the Stanford-Lancet Commission on the North American Opioid Crisis. The Lancet Regional Health–Americas, 3: 100031.
2. Vadiei, N., Axon, D. R., & Eckert, B. (2024). Naloxone Distribution Models in the United States: A Scoping Review. Substance Use & Addiction Journal, 29767342241289008.
3. Guest, G., MacQueen, K. M., & Namey, E. E. (2011). Applied thematic analysis. SAGE Publications.
4. Wright, T., & Adhikari, A. (2023). Utilizing a national wastewater monitoring program to address the US opioid epidemic: a focus on Metro Atlanta, Georgia. International Journal of Environmental Research and Public Health, 20(7), 5282.