The final sample for this study included 29 participants (see Table 1). Results (see Figure 1) are organized by larger thematic categories of accessing/accepting naloxone, carrying naloxone, and administering naloxone. Within those categories, sub-themes are mapped onto intersecting R-REF domains of physical, social, political, criminal-legal system, healthcare and economic environments.
1.1 - Knowledge: at first I was like… “ain’t no way it saves somebody’s life”
Over half of the participants (n=16) learned something new about naloxone through the intervention. Some of those 16 participants (n=5) learned about the existence and/or availability of naloxone for the first time through the C2H intervention. These participants used language like, “I had no idea what it was” when describing their previous knowledge of naloxone. Others were previously unaware of how to access naloxone or were hesitant to attempt to access it. For example, one participant expressed that she had heard about naloxone being offered in her community but was skeptical that it was available locally. “I know that sometimes they would give it out [around here]... But I was like, ‘I don't believe that. I can't believe that.’” Another discussed learning about the various places he could access naloxone through the intervention: “[Through the intervention, I learned that] the [local resource center] I think has some, down there at the Health Department… There’s a few places I can get it.”
Of the 16 participants with new naloxone knowledge, most (n=13) learned about how to administer naloxone. Participants reported that the naloxone training taught them about “the recovery positions… putting them on their side… their mouth closed, their head tilted back”; “how long it takes to kick in”, and how to time doses: “wait two-to-three minutes between each dose”
Through training, participants increased their confidence in naloxone administration:
“[My friend] said ‘You know you’re only supposed to give so many [Narcan doses] within so many minutes of one another?’ I said ‘Duh, I’ve been trained by [REHN].’ I said ‘I’ve watched the videos… I know how to use Narcan.”
– Male, County 2
Participants also gained confidence in naloxone’s efficacy:
Interviewer: Has your opinion of Narcan changed […] since joining CARE2HOPE?
Participant: Yeah, at first I was like, what the heck, ain't no way it saves somebody's life. Yeah, it does. Absolutely.
Interviewer: So, before you didn't necessarily believe that [Narcan] would work?
Participant: No, I didn't believe it, ain't no way. Yeah, it works good.
– Female, County 7
Turning to the criminal-legal system environment, some participants (n=5) described learning about the legality of naloxone from the intervention, including the fact that they could not be prosecuted for possessing it. One participant said the training taught her “that you can be arrested, you can be charged, but they can’t prosecute you and make it stick if you’re having Narcan in your pocket.” Participants shared newfound knowledge of medical amnesty policies with their social networks. “Everybody’s so afraid to call 911. And then I’m like, ‘Look, there’s a law passed. It’s American law… We’re getting this person help,” another participant offered.
Participants’ receptivity to the interventions’ naloxone-related education and resources was enhanced by relationships with REHNs. Participants expressed that their social networks were limited due in part to experienced judgment and distrust. One participant recounted when she came out of prison, “no one would trust me. Everyone waited for me to fail knowing I was going to fail.” REHNs often met participants’ relational needs by providing nonjudgmental social support rooted in understanding of local context, shared lived experience, encouragement, validation, respect for boundaries, trust, and empathy. When describing ongoing familial conflict, one participant explained “I feel like [my family] just doesn’t care. They don’t help me at all as far as transportation, or food, or communication, anything like that." When asked how her REHN had helped her navigate this period, she replied, “He checks on us… and asks how everything is going, or if we need anything. He gives us Narcan and fentanyl test strips… Things we might need.” For this participant, her relationship to her REHN contrasted with her relationship to her family and served as a source of emotional and instrumental support. Shared lived experience with REHNs fostered trust and supported the ability to receive naloxone.
“It’s nice talking to somebody that has also been through what I’ve been through, because [REHN]… has been a recovered addict as well. It really helped me, talking to [REHN]. [REHN] gave me Narcan…”
- Female, County 5
By providing instrumental support (naloxone distribution) paired with informational support (naloxone training, education, and policy information) and emotional support and solidarity, the intervention both altered participants’ healthcare environments and enabled them to become community overdose responders – i.e., a part of the healthcare environment themselves. Almost all participants (n=27), opted to accept naloxone, indicating that individuals who receive education on naloxone are likely to accept it when offered.
Just two participants opted not to accept intervention-provided naloxone. They reported that they made this decision because they had access to naloxone through other channels. One explained, “I already have Narcan… When I left the hospital, they fill your prescriptions there… and Narcan was one of them… [The hospital-provided Narcan] is in my medicine cabinet as we speak.” For the other, the decision to accept naloxone offered through the intervention was contingent upon how much naloxone he currently possessed, and possible shortages for others in need.
“I don't want to take something that somebody else could possibly use... If I had like 10 [Narcans] at home, that's enough for me for the time until I use some... I don't want to over-take something and somebody go after me and them not have it. Selfish. Because I want everybody to live.”
- Male, County 2
This participant thus invoked a community-focused mindset in which taking naloxone was contingent on his current perceived need, which can be interpreted as interplay between the healthcare and social environments. However, not everyone who accepted naloxone from C2H consistently carried it or administered it, explored below.
2: Carrying naloxone
Approximately two-thirds (n=19) of participants opted to carry naloxone at least some of the time. The C2H OEND impacted participants’ experiences of carrying naloxone by, a) providing access to naloxone, b) increasing participant confidence in their legal right to carry naloxone, c) mitigating impact of police stigma, and d) enhancing positive feelings towards naloxone.
2.1 - safer with naloxone: “you never know when you can run into someone that is overdosing”
Participants (n=10) shared that despite potential consequences, they felt safer with naloxone than they did without it. One participant said, “I feel safe and secure, a little bit more secure with [Narcan] on me.” One participant explained that carrying naloxone made him feel safer considering the fentanyl influx in his community because naloxone “helps with everything.” When describing pervasive yet unpredictable overdose patterns in their community, another participant explained,
“You can't ever tell in wherever you're at, what kind of situations going on, anything can happen in the spur of a moment. And I know as long as I've got [Narcan] on me, if something like that ever happens around me, it could save somebody's life.”
The local rural physical environment contributed to participants’ desire to carry naloxone. The combination of high overdose prevalence and suboptimal emergency response systems contributed to participants’ desire to carry their own naloxone rather than relying on an ambulance: “In rural areas, ambulance doesn't always come… time is very precious in those moments. Every second counts” one participant said. However, there were also notable barriers that influenced participants’ decisions carry naloxone, including stigma, explored below.
2.2 - Helper role: “it feels good to have a part in something”
Regarding the social environment, some participants (n=7) attributed their decision to carry naloxone to a sense of social responsibility. When discussing the factors that motivated their decision to carry naloxone, participants invoked a self-imposed social responsibility to community members – which we interpret as part of the R-REF social environment - and an enhanced sense of security associated with carrying naloxone, which we interpret as part of the criminal-legal system environment. Some participants expressed that while they were no longer actively using drugs, people within their social networks were. Carrying naloxone helped these participants feel prepared to respond to overdose in their community. Participants used language like “doing your part,” when describing their internalized role. One participant explained: “I can’t walk by somebody laying on the ground and not try to help […] That’s somebody’s daddy or mother or daughter or son […] I won’t walk by.” Participants described being known within their community as someone who has naloxone:
“People would always come running to us when they would need [Narcan], when people would OD. We actually saved eight or nine, 10 lives. People would OD, we would be the ones to have the Narcan. Everywhere we go, we got Narcan. People we don't know, we have saved their lives with Narcan […] Just because we knew we had it and they didn't.”
-Male, County 7
One participant shared that her social role as a naloxone carrier was important because “If I’m around [community members] and I have Narcan, they can’t misplace it or not be able to find it when they need it,” when describing her role as someone equipped with the tools and knowledge to respond to overdose. Another participant expressed that this social role was a source of self-esteem, explaining, “It’s like doing your part… It feels good to have a part in something.” Two participants explained that they began carrying naloxone after witnessing a friend’s overdose. For these participants, the feeling of being unequipped to respond to these witnessed overdoses spurred a significant behavioral change. One recalled “I didn’t have [Narcan] that night, and ever since, it’s always been with me.”
One participant expressed that she had not experienced social obligation in the past:
I was a very careless addict. I didn't really care. I was the type of addict on heroin that my friend would overdose in front of me and I would pick their pockets for their dope and not even call an ambulance. So I didn't really care. I didn't feel the need to have it.
-Female, County 7
Later in the interview, this participant went on to say that several recent life changes (e.g., moving, drug cessation, family loss) had led changes in her perceptions and behavior, and that she now does carry intervention-distributed naloxone with her.
The helper role was a critical driver for some participants’ (n=7) decision to carry naloxone. Participants said that they carried naloxone in part because they had access to it and their fellow community members often did not, amplifying their sense of social responsibility.
2.3 - stigma and criminal-legal systems: “wear a badge, they think they’re better than everyone else”
Stigma codified and perpetuated by law enforcement obstructed some participants’ comfort with carrying naloxone. Because all participants were criminal-legal system involved, relationships with law enforcement were rooted in prior conflict and experienced trauma. Several participants (n=5) described law enforcement stigma as something that had made them hesitant to carry naloxone:
There's times I have been stopped, afraid the law would try to charge me with something... But [that was] before I got into the CARE2HOPE. Once I got into this program, it lightened my feelings up on if I got stopped, because [Narcan] actually helps people…I realized not to worry if I've got it, because it's actually to help people.
–Male, County 7
In this participant’s case, the intervention mitigated the impact of police stigma. Through engaging with naloxone training, he both enhanced his positive feelings towards naloxone and reduced his fear of consequences to carrying it. Another participant explained that the desire to be prepared to respond to overdose outweighed the fear of arrest: “I’d rather have [Narcan] on me and go to jail [than] not being able to save someone because I don’t have it.” However, for other participants, apprehension of law enforcement stigma remained a barrier to carrying naloxone. Another participant explained, “if I’m carrying Narcan, then that’s going to make [police] judge me or question me more and wonder why I have that if I’m not actively using.”
Community-level stigma, defined as experienced and anticipated judgement from community members, was less salient to participants’ decisions to carry naloxone. Some reported that carrying naloxone was normalized in his community, stating, “Everybody I know carries it, whether they’ve done a drug in their life, they still carry it… The preacher’s got some in his glove box.” Others reported that they did not notice or care about community stigma: “even if they did [judge me], I don’t care. That’s irrelevant to me.” Conversely, one participant did describe experiencing stigma from a community member for carrying naloxone. “She seen Narcan in my car and just automatically said, ‘Oh, so you’re on [drugs] now?’ To me, that was judgmental […] Just because I have [Narcan] in my car, does not mean that I’m on drugs.”
While participants’ barriers to carrying naloxone largely stemmed from their criminal-legal system environment, barriers to administering naloxone primarily dealt with social environments.
Administering naloxone
Over half (n=16) of participants described recent experience administering C2H-provided naloxone. Fourteen participants administered C2H-provided naloxone on someone else, one participant had C2H-provided naloxone administered on her, and one participant handed someone else the naloxone to administer to another individual during an overdose event. A subgroup of participants (n=6) described administering naloxone in the past but did not have recent experience with administering C2H-provided naloxone. Another sub-group (n=6) recalled no experiences administering naloxone, before, during, or after the intervention.
Participants with recent naloxone administration experience (n=16) described a range of barriers and facilitators to administering naloxone, largely rooted in the social environment. These fell into two main categories: 1) anticipation of the recipient’s reaction, and 2) prior communication between the participant and recipient about naloxone.
3.1 - recipient reaction: “now they’re sober and they’re broke”
Participants expressed that when they used naloxone to reverse someone’s overdose, they were often met with anger and frustration upon the recipient’s revival. Participants offered various explanations for these reactions, including loss of high, acute withdrawal symptoms, and frustration of having spent limited funds on drugs they can no longer feel the effects of.
Several participants had experienced overdose reversal themselves and empathized with their peers’ response. Apprehension about administering naloxone was often rooted in first-hand knowledge of overdose reversal discomfort. Participants described rapid-onset withdrawal symptoms associated with overdose reversal. One participant explained that she had been angry with people in the past for using naloxone on her because, “You wake up sick and pissed off. You just need another shot [of heroin]… I would wake up mad as hell, then get me another shot… that way I wouldn’t be sick.” Several participants shared that they learned about the biopsychosocial experience of overdose reversal through the intervention: “[I learned] that Narcan puts you into straight withdrawals. That’s why you feel bad after you use it.”
Often, recipients’ negative reactions to overdose reversal stemmed from the loss of high in addition to the physiological withdrawal symptoms described above. Nine participants spoke to recipients’ “loss of high” as something they considered before administering naloxone. One participant recalled that in her experience administering naloxone, the recipient wakes up “swinging, madder than hell because I took their buzz away.” Similarly, another participant explained that she had seen people deny Narcan because “They didn’t want their high to go away. They were so high that it could kill them, but they didn’t want to lose their high.”
Some participants (n=3) explained that the recipients’ reactions upon revival were driven in part by feelings of having lost or “wasted” money, a feature of the economic environment. One participant explained that in her experience administering naloxone, the recipient reacts negatively because “Now they’re sober and they’re broke… I had a man that was in full overdose one time. When he come to, he said ‘…You just caused me to waste $160.’” Another participant recounted similar experiences:
Some of them are just like, "That's the only money I got. If you Narcan me and I go back to being completely sober, I'm going to be mad because, pretty much, I bought those drugs for nothing. I'm not going to feel them, and I'm not going to be able to get anymore," which, even as an addict, it's crazy to me. I just couldn't imagine being in that mindset and thinking that that high is more important than me waking up.
–Female, County 4
Participants often administered naloxone despite anticipated negative reactions, evidenced by the number of participants (n=14) who had recently administered intervention-provided naloxone. Participants’ rationale for administering naloxone despite negative consequences invoked some of the same sentiments that factored into decisions to carry naloxone (e.g., social obligation to community, helper role). One participant reasoned, “You may get hit but that’s just part of it… I’m not going to lay back and watch somebody die.” Participants were empathetic to the experience of overdose reversal, particularly when they had been on the receiving end of naloxone in the past. For another participant, the decision to administer naloxone despite potential consequences came down to considerations of the recipient’s family: “They might be having a bad day today, but that doesn’t change the fact that they have a family that’s going to have to deal with the consequences if something happens to them.”
Two participants said that anticipation of the recipient’s reaction made them delay naloxone administration or exhaust alternative options prior to trying naloxone. One participant explicitly stated that naloxone was a last resort: “I’d try to save them at all costs without using Narcan if possible… I would resort to everything but [Narcan]. Use it last.” Another participant shared that sometimes she was hesitant to administer naloxone because she feared the recipient would be upset with her. In response, she delayed administration: “I try to wait a little longer than what I usually would […]I don’t want to wait too long, but then I have it in my head, they’re going to get mad at me… It’s nerve racking.”
Participants overcame barriers to administering naloxone by weighing the consequences of naloxone administration (e.g., adverse recipient reaction) against the consequences of doing nothing (fatal overdose). The C2H intervention helped participants overcome barriers by providing access to naloxone (reducing scarcity, actual and perceived), increasing confidence in naloxone administration through training, and reducing fear of criminal-legal consequences through education. However, participants explained that the experience of administering naloxone, particularly to someone in one’s own social network, is wrought with complex social environment considerations. These are further illuminated in participants’ communication with social network members regarding expectations and intentions for naloxone administration.
3.2 - prior communication: “wait three minutes before you Narcan me”
Participants’ social environments featured discussions about the use of naloxone prior to overdose events involving a) the participant’s intention to administer naloxone if they observe signs of overdose, and/or b) the recipient’s preferences regarding if/when they wish to have their overdose reversed with naloxone.
Another component of these conversations was the recipient’s communicated desire, or lack thereof, to receive naloxone. Participants described receiving or giving instructions to wait for a specified benchmark or time limit before administering naloxone. “I usually tell people, ‘if my lips ain’t blue, don’t touch me with no Narcan,’” One participant reported that her partner told her, ‘If I go out wait at least three minutes before you Narcan me’”
These conversations often involved one party’s intention to administer naloxone despite the other party’s objections. “Some people say, ‘If I need [Narcan], don’t,’ one participant recounted. Her response: “Sorry, but I’m going to.” For some, conversations regarding intentions to administer naloxone acted as a facilitator to future naloxone administration. For others, these conversations made it more difficult to administer naloxone, particularly when the recipient expressed a strong desire not to receive naloxone. Participants shared that this barrier was often overridden by other facilitators, like social obligation to community, helper role, and positive feelings towards naloxone often developed through intervention training.