(9) Determinants of Naloxone Favorability and Carrying in the General Public

Background & Introduction: Accidental overdose remains the leading cause of death among U.S. adults aged 18-45 years, with opioids implicated in approximately 75% of fatalities. Naloxone is a safe, effective opioid antagonist that can reverse life-threatening overdoses within minutes and can be administered by bystanders via a simple intranasal spray. Despite its favorable safety profile and expanding availability, naloxone remains underutilized in the general population. While awareness and carrying rates are relatively high among individuals with opioid use disorder (OUD), only a small minority of U.S. adults report carrying naloxone, suggesting persistent gaps in knowledge, perceived relevance, and engagement in overdose response.

Recent policy initiatives, including over-the-counter pharmacy availability, insurance coverage, and community distribution, have reduced structural barriers to access. However, disparities in uptake persist, particularly among individuals without direct exposure to opioid-related harm and in rural communities. Stigma toward substance use disorders, misconceptions about harm reduction, and uncertainty regarding overdose recognition and response may further limit naloxone acceptability.

This study addresses critical gaps by examining how beliefs about OUD, stigma, overdose knowledge, naloxone familiarity and training, and orientations toward public health versus punitive approaches are associated with naloxone favorability and carrying behavior in the general public.

Methods: This cross-sectional survey study was conducted in August 2024 to assess general public knowledge, attitudes, and beliefs related to OUD, overdose response, and naloxone. A convenience sample of adults (≥18 years) residing in Minnesota were recruited at the Minnesota State Fair. Across four recruitment shifts, 566 participants enrolled. The study was approved by the University of Minnesota Institutional Review Board.

Participants completed an anonymous electronic survey via REDCap after providing informed consent. Measures included validated or adapted scales assessing stigma toward people with OUD (Difference, Disdain, and Blame Scale), beliefs about OUD as a medical condition, attitudes toward helping individuals with OUD, overdose response knowledge (Modified Rx-Opioid Overdose Knowledge Scale), naloxone familiarity, acceptability, and carrying behavior, policy attitudes toward OUD (public health vs. punitive orientation), and personal connection to OUD or overdose. Demographic information, including political orientation, was collected.

Data were analyzed in R (v4.3.1). Descriptive statistics characterized the sample. Naloxone favorability and carrying were dichotomized due to skewed distributions. Pearson correlations examined bivariate associations, and multivariable logistic regression models identified predictors of naloxone favorability and carrying, adjusting for demographics, attitudes, knowledge, and policy orientation.

Results: A total of 563 individuals completed the survey. Participants were predominantly women (67.9%), White (78.3%), and highly educated, with 70.9% holding a bachelor’s degree or higher. Most were employed full-time (57.6%), nearly half reported household incomes of $100,000 or more (49.2%), and political orientation was primarily liberal (54.6%). Due to a survey programming error, age was missing for 51.5% of respondents; among those reporting age, participants were evenly distributed across generations.

Participants demonstrated moderate stigma toward OUD (M = 4.71, SD = 1.27), though they generally endorsed viewing OUD as a medical condition (M = 2.12, SD = 0.85) and supported public health–oriented approaches over punitive responses (M = 4.01, SD = 0.79). Overdose response knowledge was relatively high, with participants answering an average of one question incorrectly (M = 6.03, SD = 1.30). Respondents reported moderate endorsement of active helping strategies (M = 3.19, SD = 0.76) and low endorsement of avoidance strategies (M = 1.47, SD = 0.67).

Nearly one-third of participants reported a personal connection to someone with current or past OUD (30.7%), and 26.4% reported knowing someone who had experienced an overdose. While most respondents reported favorable attitudes toward naloxone (80.5%), the majority indicated that they never carry naloxone (87.8%).

In multivariable logistic regression models, favorable attitudes toward naloxone were associated with greater familiarity with naloxone (OR = 1.31, 95% CI = 1.01–1.69), higher overdose response knowledge (OR = 1.48, 95% CI = 1.22–1.82), and stronger endorsement of public health–oriented OUD policies (OR = 2.52, 95% CI = 1.83–3.53). Naloxone carrying was more likely among men (OR = 3.19, 95% CI = 1.41–7.37) and those with greater familiarity with naloxone (OR = 1.62, 95% CI = 1.16–2.33), as well as individuals who obtained naloxone information through self-education (OR = 5.19, 95% CI = 2.38–11.69) or expert-led training (OR = 4.77, 95% CI = 2.03–11.36). Naloxone carrying was less likely among White participants compared to non-White participants (OR = 0.39, 95% CI = 0.15–0.99), those identifying as politically conservative compared to politically liberal (OR = 0.20, 95% CI = 0.06–0.66), individuals unaware of where to obtain naloxone (OR = 0.63, 95% CI = 0.45–0.88), and those with higher overdose response knowledge (OR = 0.65, 95% CI = 0.50–0.85).

Conclusion & Discussion: In this community-based sample, most participants reported favorable attitudes toward naloxone; however, the majority had never carried it, highlighting a persistent gap between acceptability and harm reduction behavior. Consistent with prior literature, support for public health-oriented approaches to OUD, greater familiarity with naloxone, and higher overdose response knowledge were associated with more favorable naloxone attitudes. In contrast, naloxone carrying was driven primarily by practical and structural factors, including awareness of where to obtain naloxone and participation in self-directed or expert-led naloxone education. Sociopolitical differences in naloxone carrying further align with evidence that engagement with harm reduction varies by ideology and social context. Notably, higher overdose response knowledge was inversely associated with naloxone carrying, suggesting that knowledge alone may not translate into preparedness.

Study strengths include a large, community-based sample and the use of validated measures assessing attitudes, knowledge, and behavior. Limitations include convenience sampling, missing age data, and a cross-sectional design that precludes causal inference. These findings underscore the need for interventions that pair public health-oriented messaging with naloxone education and access strategies. Future research should examine mechanisms linking knowledge to behavior and evaluate targeted approaches to increase naloxone carry among the general public.

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