(8) Naloxone Vending at Jail Release Works Without Mandatory Overdose Education

Background & Introduction: Opioid overdose remains a leading cause of preventable death in the United States, with risk disproportionately concentrated among justice-involved populations. Individuals released from incarceration face an especially elevated risk of fatal overdose in the immediate post-release period, driven by reduced opioid tolerance, polysubstance exposure, and limited access to care and harm reduction resources.1-3 Naloxone-on-release programs have demonstrated effectiveness in reducing overdose mortality,4-5 yet implementation in carceral settings has been constrained by logistical barriers, staffing limitations, and training requirements.6-8

To address these challenges, an increasing number of jail systems have adopted low-barrier naloxone dispensing strategies, including health vending machines placed in release areas. However, limited participant-level data exist regarding engagement with overdose education components and naloxone uptake within these programs, particularly for vending machine–based models. The Los Angeles County Jail system implemented a universal naloxone-on-release program combining video-based overdose education with autonomous naloxone dispensing via vending machines, representing the largest program of its kind.

The objective of this study was to examine participant-level engagement with overdose education and naloxone dispensation at jail release, and to identify demographic, substance use, and incarceration-related factors associated with naloxone uptake in this large, real-world jail-based intervention.

Methods: This study used a cross-sectional observational design to examine participant-level engagement with overdose education and naloxone dispensation within a large jail-based naloxone-on-release program in the Los Angeles County Jail system. Data were collected from a random sample of individuals released from custody who passed through a centralized release area equipped with a continuously looping overdose education and naloxone distribution (OEND) video and an autonomous health vending machine dispensing free naloxone and drug checking supplies.

Participants completed a brief survey assessing demographic characteristics, substance use history, overdose experiences, incarceration history, recall of OEND video content, and naloxone dispensation behaviors. Primary outcomes included self-reported viewing of the OEND video and naloxone dispensation from the jail-based vending machine at release. Descriptive statistics were used to characterize engagement with overdose education and naloxone uptake. Bivariate associations between participant characteristics and naloxone dispensation, as well as between participant characteristics and OEND video viewing, were examined using chi-square tests of independence. Additional stratified chi-square analyses assessed the relationship between OEND video viewing and naloxone dispensation across demographic, substance use, overdose history, and incarceration-related variables to explore potential effect modification.

Results: Participants reported extensive overdose-related experiences. Approximately one-third reported a lifetime history of non-fatal overdose, nearly 90% reported having witnessed at least one overdose, and approximately half reported having responded to an overdose, indicating substantial personal and community exposure to overdose events among justice-involved individuals.

Engagement with the overdose education and naloxone distribution (OEND) video was limited. Only 27% of participants reported viewing the video at release. Among those who viewed the video, recall of content varied: approximately one-third recalled information related to overdose prevention, about half recalled information on overdose response, and 31% recalled information on where to access naloxone in the community. Recall of information related to legal considerations was less common. Notably, fewer than 10% of participants reported that the video provided entirely new information, although 15% reported learning new information related specifically to overdose response.

Bivariate analyses showed that OEND video viewing was associated with being male and with longer length of stay during the current incarceration episode. Video viewing was not associated with race, substance use history, prior overdose experiences, or perceived personal or community overdose risk. Participants who viewed the video more often reported repeated exposure to the same content during incarceration, whereas non-viewing was frequently attributed to limited visibility, technical issues (e.g., the video being turned off or inaudible), competing demands during the release process, limited time, and perceptions that the content was repetitive or not relevant.

Naloxone uptake at release was modest. Nineteen percent of participants dispensed naloxone from the jail-based vending machine at the time of release, and 30% reported having previously dispensed naloxone from the same machine during an earlier release. Participants who dispensed naloxone most commonly cited concern about experiencing an overdose themselves, witnessing an overdose, or providing naloxone to someone in their social network. In contrast, participants who did not dispense naloxone cited lack of awareness of the vending machine and free naloxone availability, low perceived overdose risk, and logistical or procedural barriers during release, such as exiting through areas without vending machines or being rushed by staff.

Naloxone dispensation did not differ by gender or race. Uptake was significantly associated with indicators of perceived overdose risk, including recent heroin use, lifetime amphetamine or speedball use, having witnessed an overdose, greater lifetime incarceration, and prior use of the jail-based vending machine. Viewing the OEND video was not significantly associated with naloxone dispensation in the overall sample.

Conclusion & Discussion: This study provides participant-level evidence on engagement with overdose education and naloxone-on-release among justice-involved individuals at jail release. Engagement with video-based overdose education was low, and video viewing was not associated with naloxone dispensation. Naloxone uptake was instead associated with perceived personal/community overdose risk, prior vending machine use, and substance use patterns linked to elevated overdose risk. These findings suggest that passive video education delivered in the release area may have limited impact on motivating naloxone uptake in this context.

Clinically and from a policy perspective, results support low-barrier naloxone-on-release approaches that prioritize autonomous access. Jail-based naloxone vending machines may offer an equitable, scalable distribution strategy without delaying release or burdening staff—an increasingly relevant consideration given naloxone’s over-the-counter availability. Findings also indicate the need to reconsider how overdose education is delivered (e.g., concise posted information or education in settings with more time to engage) and to strengthen signage and communication to increase awareness and visibility of naloxone vending machines at release.

Limitations include a sample with disproportionately more men than women, reliance on self-reported overdose knowledge, and limited qualitative exploration. Findings may also reflect the robust overdose prevention context of California and may not generalize to settings with fewer resources.

References: Binswanger IA, Stern MF, Deyo RA, Heagerty PJ, Cheadle A, Elmore JG, Koepsell TD, 2007. Release from prison — a high risk of death for former inmates. N. Engl. J. Med 356, 157–165.
Bird SM, McAuley A, Perry S, Hunter C. Effectiveness of Scotland’s National Naloxone Programme for reducing opioid‐related deaths: a before (2006–10) versus after (2011–13) comparison. Addiction. 2016;111(5):883-891. doi:10.1111/add.13265
Horton M, McDonald R, Green TC, et al. A mapping review of take-home naloxone for people released from correctional settings. Int J Drug Policy. 2017;46:7-16. doi:10.1016/j.drugpo.2017.05.015
Showalter D, Wenger LD, Lambdin BH, Wheeler E, Binswanger I, Kral AH. Bridging institutional logics: Implementing naloxone distribution for people exiting jail in three California counties. Soc Sci Med. 2021;285:114293. doi:10.1016/j.socscimed.2021.114293
Victor G, Hedden-Clayton B, Lenz D, Attaway PR, Ray B. Naloxone vending machines in county jail. J Subst Use Addict Treat. 2024;167:209521. doi:10.1016/j.josat.2024.209521.