The role of fear in harm reduction: Misinformation’s impact on naloxone use

Background: The U.S. is undergoing an opioid overdose crisis. Harm reduction (HR) policies are associated with decreased overdose deaths and incidence of communicable diseases, yet legality of HR policies differs across U.S. jurisdictions. College student perceptions of HR policies are underexplored, even though their voting behavior has increased in recent years. We sought to compare their support of different HR policies and to explore relationships between demographic characteristics and support for HR policies. Methods: We collected cross-sectional, convenience sample survey data from undergraduate students at two large public universities, one in the Midwest and one in the Southeast, during Fall 2018/Spring 2019. We analyzed data using descriptive statistics and logistic regressions. Results: The final sample included 1,263 respondents. Good Samaritan laws (n = 833, 66%) and naloxone distribution (n = 476, 37.7%) were most commonly supported, while heroin maintenance treatment (n = 232, 18.4%) and heroin decriminalization (n = 208, 16.5%) were least supported. Democrat/liberal or less religious/spiritual respondents supported HR policies more than their Republican/conservative or religious/spiritual counterparts. Midwestern students were more likely to support syringe services programs. Conclusion: HR education initiatives could target religious and/or Republican/conservative students, as they have lower HR support. Among HR policies, Good Samaritan policies may be easiest to pass in college communities.

BackgroundThe COVID-19 pandemic has amplified the need for wide deployment of effective harm reduction strategies in preventing opioid overdose mortality. Placing naloxone in the hands of key responders, including law enforcement officers who are often first on the scene of a suspected overdose, is one such strategy. New York State (NYS) was one of the first states to implement a statewide law enforcement naloxone administration program. This article provides an overview of the law enforcement administration of naloxone in NYS between 2015 and 2020 and highlights key characteristics of over 9000 opioid overdose reversal events.MethodsData in naloxone usage report forms completed by police officers were compiled and analyzed. Data included 9133 naloxone administration reports by 5835 unique officers located in 60 counties across NYS. Descriptive statistics were used to examine attributes of the aided individuals, including differences between fatal and non-fatal incidents. Additional descriptive analyses were conducted for incidents in which law enforcement officers arrived first at the scene of suspected overdose. Comparisons were made to examine year-over-year trends in administration as naloxone formulations were changed. Quantitative analysis was supplemented by content analysis of officers’ notes (n = 2192).ResultsIn 85.9% of cases, law enforcement officers arrived at the scene of a suspected overdose prior to emergency medical services (EMS) personnel. These officers assessed the likelihood of an opioid overdose having occurred based on the aided person’s breathing status and other information obtained on the scene. They administered an average of 2 doses of naloxone to aided individuals. In 36.8% of cases, they reported additional administration of naloxone by other responders including EMS, fire departments, and laypersons. Data indicated the aided survived the suspected overdose in 87.4% of cases.ConclusionsWith appropriate training, law enforcement personnel were able to recognize opioid overdoses and prevent fatalities by administering naloxone and carrying out time-sensitive medical interventions. These officers provided life-saving services to aided individuals alongside other responders including EMS, fire departments, and bystanders. Further expansion of law enforcement naloxone administration nationally and internationally could help decrease opioid overdose mortality.

Policy actor views on structural vulnerability in harm reduction and policymaking for illegal drugs: A qualitative study.

Background: With the rapid rise in opioid overdose-related deaths, state policy makers have expanded policies to increase the use of naloxone by emergency medical services (EMS). However, little is known about changes in EMS naloxone administration in the context of continued worsening of the opioid crisis and efforts to increase use of naloxone. This study examines trends in patient demographics and EMS response characteristics over time and by county urbanicity. Methods: We used data from the 2013–2016 National EMS Information System to examine trends in patient demographics and EMS response characteristics for 911-initiated incidents that resulted in EMS naloxone administration. We also assessed temporal, regional, and urban–rural variation in per capita rates of EMS naloxone administrations compared with per capita rates of opioid-related overdose deaths. Results: From 2013 to 2016, naloxone administrations increasingly involved young adults and occurred in public settings. Particularly in urban counties, there were modest but significant increases in the percentage of individuals who refused subsequent treatment, were treated and released, and received multiple administrations of naloxone before and after arrival of EMS personnel. Over the 4-year period, EMS naloxone administrations per capita increased at a faster rate than opioid-related overdose deaths across urban, suburban, and rural counties. Although national rates of naloxone administration were consistently higher in suburban counties, these trends varied across U.S. Census Regions, with the highest rates of suburban administration occurring in the South. Conclusions: Naloxone administration rates increased more quickly than opioid deaths across all levels of county urbanicity, but increases in the percentage of individuals requiring multiple doses and refusing subsequent care require further attention.

Training law enforcement to respond to opioid overdose with naloxone: Impact on knowledge, attitudes, and interactions with community members

We determined the factors that affect naloxone (Narcan) administration in drug overdoses, including the certification level of emergency medical technicians (EMTs). In 2012, 42 states contributed all or a portion of their ambulatory data to the National Emergency Medical Services Information System. We used a logistic regression model to measure the association between naloxone administration and emergency medical services certification level, age, gender, geographic location, and patient primary symptom. The odds of naloxone administration were much higher among EMT-intermediates than among EMT-basics (adjusted odds ratio [AOR] = 5.4; 95% confidence interval [CI] = 4.5, 6.5). Naloxone use was higher in suburban areas than in urban areas (AOR = 1.41; 95% CI = 1.3, 1.5), followed by rural areas (AOR = 1.23; 95% CI = 1.1, 1.3). Although the odds of naloxone administration were 23% higher in rural areas than in urban areas, the opioid drug overdose rate is 45% higher in rural communities. Naloxone is less often administered by EMT-basics, who are more common in rural areas. In most states, the scope-of-practice model prohibits naloxone administration by basic EMTs. Reducing this barrier could help prevent drug overdose death.

Living with addiction: The perspectives of drug using and non-using individuals about sharing space in a hospital setting

Abstract. Background: Harm reduction is an integral component of Australia’s overall national drug policy. Harm reduction policy and interventions can be applied to any legal or illegal drug to mitigate harm without necessarily reducing use, but harm reduction is traditionally conceptualised in relation to injecting drug use. Early and comprehensive adoption of many innovative harm reduction interventions has meant that Australia has had significant success in reducing a number of drug related harms, avoided disease epidemics experienced in other countries, and established programs and practices that are of international renown. However, these gains were not easily established, nor necessarily permanent. Aim: In this paper we explore the past and present harm reduction policy and practice contexts that normalised and facilitated harm reduction as a public health response, as well as those converse contexts currently creating opposition to additional or expanded interventions. Importantly, this paper discusses the intersection between various interventions, such as needle and syringe distribution and drug treatment programs. Finally, we detail some of the practical lessons that have been learned via the Australian experience, with the hope that these lessons will assist to inform and improve international harm reduction implementation.

The response to drug use in Laos has focused on reducing opium supply (supply reduction) and rates of drug use (demand reduction). However, recently there is increased interest among government counterparts to discuss and develop broader responses to injecting drug use (IDU) including the introduction of harm reduction programs. The concept of harm reduction has just been introduced to Lao PDR and as yet there is no agreement on a definition of the concept. We highlight here a range of issues that remain controversial in Lao PDR in the HIV, drug use and harm reduction discourse, the definition of 'harm reduction' and related terms; and the scope of harm reduction.This was a qualitative study, consisting of in-depth interviews with 27 law enforcement and 8 health officers who work in the fields of HIV and/or drug control about their understanding of HIV related to drug use, and concepts of harm reduction. Content analysis was performed to identify the coding, categories and themes.We found that law enforcement officers in particular had limited understanding about harm reduction and the feasibility and appropriateness of harm reduction services in the Lao context.Harm reduction should be a core element of a public health response to HIV where drug use and IDU exists. Recommendations include the necessity of increasing the awareness of harm reduction among law enforcement officers and providing appropriate evidence to support the needs of harm reduction policy and programs. HIV prevention and treatment strategies should be integrated within existing social and cultural frameworks, working with the task force for HIV/IDU and other government counterparts.

As with other Parts of the 2015 American Heart Association (AHA) Guidelines Update for Cardiopulmonary Resuscitation (CPR) and Emergency Cardiovascular Care (ECC), Part 5 is based on the International Liaison Committee on Resuscitation (ILCOR) 2015 international evidence review process. ILCOR Basic Life Support (BLS) Task Force members identified and prioritized topics and questions with the newest or most controversial evidence, or those that were thought to be most important for resuscitation. This 2015 Guidelines Update is based on the systematic reviews and recommendations of the 2015 International Consensus on CPR and ECC Science With Treatment Recommendations , “Part 3: Adult Basic Life Support and Automated External Defibrillation.”1,2 In the online version of this document, live links are provided so the reader can connect directly to the systematic reviews on the ILCOR Scientific Evidence Evaluation and Review System (SEERS) website. These links are indicated by a combination of letters and numbers (eg, BLS 740). We encourage readers to use the links and review the evidence and appendix. As with all AHA Guidelines, each 2015 recommendation is labeled with a Class of Recommendation (COR) and a Level of Evidence (LOE). The 2015 Guidelines Update uses the newest AHA COR and LOE classification system, which contains modifications of the Class III recommendation and introduces LOE B-R (randomized studies) and B-NR (nonrandomized studies) as well as LOE C-LD (based on limited data) and LOE C-EO (consensus of expert opinion). The AHA process for identification and management of potential conflicts of interest was used, and potential conflicts for writing group members are listed at the end of each Part of the 2015 Guidelines Update. For additional information about the systematic review process or management of potential conflicts of interest, see “Part 2: Evidence Evaluation and Management of Conflicts of Interest” in this …

Background: Naloxone administration has recently been associated with increased survival to hospital discharge for survivors of out-of-hospital cardiac arrest. However, this study was limited to retrospective data and selection bias. This study aims to determine if Emergency Medical Services (EMS) cardiac arrest protocols have changed related to recommendation of naloxone since recent interest in Narcan for overdose-associated out-of-hospital cardiac arrest (OA-OHCA). Methods: We performed a cross-sectional review of statewide EMS protocols (STP) in the United States in 2018 and 2025 as a measure of EMS clinical standards related to naloxone use in OA-OHCA. We evaluated nontraumatic cardiac arrest protocols to determine if there was a change in their recommendation related to the use of naloxone. Protocols were downloaded from each state’s EMS website or, if a protocol was not publicly available, the state medical director was contacted. The institutional review board reviewed this study and deemed it to be exempt. Results: A 2025 STP was found for 32/51 (62.7%) states and a 2018 STP was found for 25/51 (49.0%) states. In 2025, 7/32 (21.9%) states recommended the use of naloxone in OA-OHCA in the cardiac arrest protocol. Of these, 3/7 (42.9%) states added this recommendation between 2018 and 2025. Vermont recommended naloxone because “it can be difficult to discern true cardiac arrest from an opioid overdose patient with deep CNS and cardiovascular depression.” Michigan and Nebraska recommended naloxone if opioid overdose is suspected. In 2025, 3/32 (9.4%) states explicitly stated there is no benefit in using naloxone in out-of-hospital cardiac arrest in their cardiac arrest protocol. In non-cardiac arrest protocols, one additional state, New York, recommended naloxone in OHCA in their overdose protocol. Four additional states (Maine, DC, North Dakota, Wisconsin) explicitly stated there is no benefit in using naloxone in out-of-hospital cardiac arrest. Conclusion: Three states have altered cardiac arrest protocols since 2018 to recommend naloxone in out-of-hospital cardiac arrest. While this study is limited to statewide protocols, this demonstrates variations in STP recommendations regarding naloxone administration given the weak evidence supporting its use. Limitations include that local and regional protocols are excluded and that STPs may not reflect EMS clinician clinical practice.

The opioid crisis is a growing concern for Americans, and it has become the leading cause of injury-related death in the United States. An adjunct to respiratory support that can reduce this high mortality rate is the administration of naloxone by Emergency Medical Services (EMS) practitioners for patients with suspected opioid overdose. However, clear evidence-based guidelines to direct EMS use of naloxone for opioid overdose have not been developed. Leveraging the recent Agency for Healthcare Research and Quality (AHRQ) systematic review on the EMS administration of naloxone for opioid poisonings, federal partners determined the need for a clinical practice guideline for EMS practitioners faced with suspected opioid poisoning. Project funding was provided by the National Highway Traffic Safety Administration, Office of EMS, (NHTSA OEMS), and the Health Resources and Services Administration, Maternal and Child Health Bureau’s EMS for Children Program (EMSC). The objectives of this project were to develop and disseminate an evidence-based guideline and model protocol for administration of naloxone by EMS practitioners to persons with suspected opioid overdose. We have four recommendations relating to route of administration, all conditional, and all supported by low or very low certainty of evidence. We recommend the intravenous route of administration to facilitate titration of dose, and disfavor the intramuscular route due to difficulty with titration, slower time to clinical effect, and potential exposure to needles. We equally recommend the intranasal and intravenous routes of administration, while noting there are variables which will determine which route is best for each patient. Where we are unable to make recommendations due to evidence limitations (dosing, titration, timing, and transport) we offer technical remarks. Limitations of our work include the introduction of novel synthetic opioids after many of the reviewed papers were produced, which may affect the dose of naloxone required for effect, high risk of bias and imprecision in the reviewed papers, and the introduction of new naloxone administration devices since many of the reviewed papers were published. Future research should be conducted to evaluate new devices and address the introduction of synthetic opioids.

Given the potential to expand naloxone supply through community pharmacy, the aim of this study was to estimate Australian pharmacists': (1) level of support for overdose prevention, (2) barriers and facilitators for naloxone supply and (3) knowledge about naloxone administration. Online survey from nationally representative sample of community pharmacies. Australia, September-November 2015. A total of 1317 community pharmacists were invited to participate with 595 responses (45.1%). We assessed attitudes towards harm reduction, support for overdose prevention, attitudes and knowledge about naloxone. We tested the association between attitudes towards harm reduction and different aspects of naloxone supply. Pharmacists were willing to receive training about naloxone (n=479, 80.5%) and provide naloxone with a prescription (n=537, 90.3%). Fewer (n=234, 40.8%) were willing to supply naloxone over-the-counter. Positive attitudes towards harm reduction were associated with greater willingness to supply naloxone with a prescription [odds ratio (OR)=1.15, 95% confidence interval (CI)=1.11-1.19] and over-the-counter (OR=1.13, 95% CI=1.09-1.17). Few pharmacists were confident they could identify appropriate patients (n=203, 34.1%) and educate them on overdose and naloxone use (n=190, 31.9%). Mean naloxone knowledge scores were 1.8 (standard deviation 1.7) out of 5. More than half the sample identified lack of time, training, knowledge and reimbursement as potential barriers for naloxone provision. Community pharmacists in Australia appear to be willing to supply naloxone. Low levels of knowledge about naloxone pharmacology and administration highlight the importance of training pharmacists about overdose prevention.

Events such as the Australian heroin shortage are rare. They have been even less often studied systematically using the rich array of data available in the Australian case. The interpretation of ecological data is fraught with difficulties, so we welcome the insightful commentaries on our paper [1]. Our responses to them are divided into two broad categories: comments on the consequences of the heroin shortage and our interpretation of them; and the policy implications to be drawn from the shortage. We agree that the huge drop in fatal and non-fatal overdoses was the most striking consequence of the Australian heroin shortage. Gossop [2] queried two of our interpretations: first, could we be sure, he asked, that a reduction in numbers of syringes dispensed by needle and syringe programmes meant that injecting drug use had declined? His substantive point is that frequency of injection may have changed; this could have been the case for VIC, but was less clear for NSW. Our interpretation was based upon two key findings: the sustained reduction in numbers of syringes distributed in NSW after a decade long increase in numbers, and a drop in HCV notifications among young people [3], which suggests that there was not a huge increase in numbers engaging in stimulant injecting. Moreover, the interpretation of these data was supported by key experts and other data derived from those working with the population, who reported reductions in the number of young people presenting to services [3, 4]. Secondly, can we be sure that the heroin shortage has produced a ‘net gain’? We believe so for the study period to date. The main reason is the very large reductions in heroin-related mortality (of the order of 300–400 fewer deaths) and morbidity and either no increase or a small reduction in property crime. The reduction in mortality alone is a very large gain in life years among young adults, and it was not obviously outweighed during the period of study by any offsetting increases in problems related to methamphetamine and cocaine use, which increased only very modestly. We agree with Weatherburn that the net positive consequences of the shortage to date may not have occurred if other circumstances had not been so propitious, including reductions in cocaine availability (after the increases initially seen in NSW [5, 6]), increased treatment access (and other forms of demand and harm reduction that are well-established in Australia), and increased male employment. Jaffe [7] comments on the fact that there did not appear to be a switch from smoking or snorting of heroin to injection as a consequence of the reduction in quality and increase in price of the drug. It is important to note that most heroin users in Australia were already using injection as a route of administration; his concern—that such a supply change in countries where intranasal or smoking as routes of administration were common—might be an issue of concern, and it reinforces our belief that harm and demand reduction efforts (discussed below) are critically important alongside supply side interventions, to attempt to reduce the harm resulting from any such shifts. The very modest effects on crime might be considered puzzling, given the long-standing assumption (supported by reasonable evidence and a moderate aetiological fraction) that some proportion of property crime in Australia is heroin-related. Reuter [8] and Caulkins [9] were less puzzled, suggesting that modest effects should be expected because of the shift in drug purchases to others drugs and an inelasticity of demand for heroin and other drugs among more dependent heroin users who were less likely to cease heroin use and more likely to switch to methamphetamine. Caulkins [9] also argues that more economically informed structural modelling analyses of the time-series would not have tested for the effects that we did. We agree that more economically informed modelling is desirable. The time-series analyses of the effect of the heroin shortage were developed on the fundamental assumption that we have limited knowledge about heroin price, availability and purity measures that could be used to assess direct effects of the shortage on heroin markets. We therefore examined indicators of heroin-related harms, in order to describe the major effects of an abrupt change in a heroin market and how these would be manifested across the different jurisdictions under study. We feel that economists should consider using the results of this data-based modelling strategy to infer new information about drug markets, which they can perhaps then test with innovative research methods on the available indicator data. Time-series modelling was largely to decide which changes could not be attributed to chance. The comments of Mann [10] were interesting in that he felt that they corresponded to predictable, previously documented phenomena in the alcohol field. We would welcome the collaboration of experts in more detailed and economically informed analyses of the time-series data that we have collected. Several commentators have essentially asked the question as to whether the Australian heroin shortage represents a victory for supply side drug policies [11-13]? The rush by some to proclaim the Australian heroin shortage as a ‘victory’ for supply control policy has been answered by an equally swift and reflexive rejection of this possibility by some proponents of demand and harm reduction policies. Both responses are understandable. The supply-side of the drug policy debate has not had many unequivocal wins; and sceptics of supply side efforts often point to studies in Australia, Canada, the United Kingdom and the United States that have failed to detect any impact of drug seizures on drug price and other indicators of drug use [14, 15]. Mark Tyndall's commentary [12] represents one example of understandable concern that our work is not taken to represent a view that aggressive supply-side interventions should be the sole or major focus of drug policy, a view that we strongly support. Unfortunately, the polarization of opinion about the causes and policy lessons of the Australian heroin shortage has hampered the task of describing and understanding the event and its most immediate consequences. Before extracting policy implications from the event, we considered it important to carefully document its effects. We did not discuss the causes of the shortage in this paper for the reasons just given. Several of the authors have done so in detail elsewhere, where they came to the conclusion (largely on the basis of the implausibility of any of the alternative explanations) that supply reduction efforts by law enforcement, targeted at high level internationally run trafficking syndicates, contributed in part to the shortage [16], the effects of which were mediated by steep increases in the price of heroin, as indicated by Reuter [8]. We feel that it was the successful disruption of high level trafficking syndicates, rather than the scale of seizures per se, that was important in this instance [16]. The longer-term effects of the shortage may not prove to be as positive as they have been in the short term. We agree with Caulkins [9] and Gossop [2] that these changes are likely to prove transitory in the longer term and that the public health and order effects of the shift to methamphetamine injecting may prove very unwelcome. Some front-line police and health staff are already comparing the effects of methamphetamine use on injectors unfavourably with the effects of heroin use. There are also strong reasons to doubt the reproducibility of the Australian experience in other similar countries, whatever we take its causes to be. As Weatherburn [13] points out, the application of Australia's experience is limited given Australia's geography, the small size of its population and drug market in international terms, and its distance from the major source countries. Further, the differences in the way in which the shortage was manifested across the different jurisdictions suggests that local conditions will also affect outcomes. It may not even be possible to apply lessons from heroin to methamphetamine in Australia because methamphetamine is, in large part, domestically produced, which presents a very different set of problems for law enforcement and health. Finally, we think it important to remember that Australia has a history of timely and innovative implementation of novel harm reduction measures, and good implementation of demand reduction measures that (in this case) importantly include steadily increasing treatment places for opioid pharmacotherapy and widespread needle and syringe programmes. Without such established programmes, reductions in heroin supply may have had dramatically different (and negative) outcomes. Rather than signalling a ‘win’ for supply reduction, we argue that the results of this study [6, 17-19] suggest that a modicum of success in one facet of drug policy may be better achieved in the context of established success in the others.

Bill Aimed at Replicating Oregon Mobile Crisis Program