The Decision to Not Carry Naloxone Among People Who Use Drugs in Rhode Island: A Mixed-Methods Analysis of Harm Reduction Surveillance System Survey Data, 2021 to 2024

BACKGROUND: Opioid-related fatal overdoses have increased over the past decade in the United States, including in Rhode Island (RI). Naloxone (Narcan) is a medication that can quickly reverse opioid-involved overdoses. Understanding why people do not carry naloxone is critical to inform prevention and outreach efforts to increase naloxone coverage among those most at risk for experiencing or witnessing an overdose. METHODS: This convergent parallel mixed methods study used pooled data from the RI Harm Reduction Surveillance System survey from 2021 to 2024 to describe reasons why people who use non-prescribed substances in RI reported not carrying naloxone. We first conducted descriptive and bivariate analyses of respondents' demographics and key variables of interest. Then we used thematic coding to develop and assign themes for respondents' open-ended responses on their decision to not carry naloxone with a team of 3 coders. RESULTS: Of the 670 respondents, 40% reported not currently carrying naloxone, with most of those not carrying naloxone reporting using non-opioid substances. Among individuals who did not carry naloxone, 54% witnessed and 20% personally experienced an overdose in the last 12 months. Many described not feeling personally at risk for an opioid overdose or lacked awareness of how to use naloxone. Stigma and not wanting the responsibility or trauma of administering naloxone was described throughout responses. Others indicated having naloxone confiscated or questioned by police, keeping it at another location, or having recently used or lost it. CONCLUSION: This study illuminated reasons for not carrying naloxone, primarily related to stigma, discomfort with administration, or a lack of awareness/risk perception for an opioid-related overdose. More prevention and education work are needed to increase carrying and confidence in administration of naloxone among people who use drugs and people likely to witness an overdose in RI.