Overdose education and naloxone distribution programs, also known as naloxone trainings, are a key strategy for reducing overdose fatalities. These programs expand access to overdose reversal medication and prepare lay responders to intervene in an overdose situation. Naloxone trainings have been shown to improve knowledge and self-efficacy related to opioid overdose management and result in successful overdose reversal (Razaghizad et al., 2021).
The expansion of naloxone initiatives, however, has been challenged by stigma toward drug use and concerns that access to naloxone may encourage risky behavior (Greene, 2018). Stigma can deter people who may benefit from naloxone from accessing this lifesaving medication. For example, people who use opioids and their caregivers worry about being judged or mistreated when requesting naloxone in pharmacy settings (Green et al., 2017), and lay responders report concerns about potential consequences if they were found to be carrying naloxone by the police (Bennett et al., 2020; Fomiatti et al., 2020). The consequences of stigma toward naloxone are likely compounded by racism among minoritized racial-ethnic groups.
In an article recently published in Stigma and Health, my colleagues and I examined the deleterious effect of stigma on naloxone training outcomes. While prior research has documented the impact of stigma on the availability and uptake of naloxone (Tobin et al., 2018; Tsai et al., 2019), we wanted to understand how stigma affects the efficacy of training among those who attend. We surveyed adults who attended a naloxone training in Michigan, assessing their perceptions of stigma toward naloxone, knowledge of opioid overdose management, and attitudes toward opioid overdose response.
We found that regardless of race or ethnicity, people who perceived greater stigma toward naloxone tended to have less positive attitudes toward overdose response. This means they felt less confident in their ability to manage an overdose and were less willing to intervene in an overdose situation. However, the effect of perceived stigma on knowledge of overdose management varied by race1. For White participants, greater perceived stigma was associated with lower levels of knowledge of overdose management. Among Black participants, we found the opposite trend (i.e., knowledge increased as perceived stigma increased), though the association did not reach statistical significance. The effect of stigma on knowledge and attitudes was not different for people who identified as a race/ethnicity other than Black or White compared to those who identified as White. These findings suggest stigma toward naloxone operates differently for White and Black training participants.
Our study is not the first to find differences in perceptions of and responses to drug-related stigma by racial-ethnic identity (Keyes et al., 2010; Minior et al., 2003; Semple et al., 2005). In understanding why the effect of stigma varies by race, race should be considered a proxy for experiences of racism (Lett et al., 2022). The role of racism in US drug policy is well-documented. Although Black people and White people use drugs at similar rates, Black people are arrested more frequently and sentenced more harshly for drug crimes (James & Jordan, 2018). Recent efforts to remove moral attributions and frame opioid use as a public health problem affecting rural and suburban communities have further marginalized Black people who use drugs, who remain underserved in the current overdose crisis. As a result, overdose death rates among Black individuals have risen sharply in recent years, surpassing the rate among White individuals in 2020 (Friedman & Hansen, 2022).
Given the legacy of racism in US drug laws and policing, for Black people, greater perceived stigma toward naloxone may lead to a state of hypervigilance. Hypervigilance is a chronic state of alertness or readiness to respond to threats in the environment, and has been identified as a consequence of stigma, for example among LGBTQ-identified people (Rostosky et al., 2022). Black people who perceive greater stigma toward naloxone may be hypervigilant for potential harm associated with carrying naloxone, which may lead them to learn everything they can about opioid overdose response. It’s also possible that among Black participants, greater knowledge leads to greater perceived stigma toward naloxone. While for White participants, education about naloxone may reduce perceptions of stigma, for Black participants, increased knowledge may heighten awareness of one’s vulnerability to racist policies and practices.
Our study highlights a need for multiple, varied efforts to address the link between stigma and naloxone training outcomes. For White individuals, efforts to reduce public stigma toward opioid use and naloxone may improve training outcomes. However, structural interventions – such as decriminalization or police alternatives to overdose response – may be needed to address stigma toward naloxone among Black participants. Interventions to reduce stigma toward naloxone among criminal legal and healthcare professionals may help alleviate fear of repercussions among Black people who carry naloxone. In the meantime, it is crucial that Black leaders and organizations be centered in the creation and implementation of naloxone training programs. Members of the Black community can help identify concerns that training should address and develop stigma reduction messages that are culturally appropriate. Identifying culturally relevant strategies to address stigma toward naloxone will be fundamental to reducing racial disproportionality in overdose fatalities.
Dr. Emily Pasman is a licensed social worker and Postdoctoral Research Fellow at the Center for the Study of Drugs, Alcohol, Smoking, and Health at the University of Michigan. Connect with her via email at [email protected].
Bennett, A. S., Freeman, R., Jarlais, D. C. D., & Aronson, I. D. (2020). Reasons people who use opioids do not accept or carry no-cost naloxone: Qualitative interview study. JMIR Formative Research, 4(12), e22411. https://doi.org/10.2196/22411
Fomiatti, R., Farrugia, A., Fraser, S., Dwyer, R., Neale, J., & Strang, J. (2020). Addiction stigma and the production of impediments to take-home naloxone uptake. Health, 1363459320925863. https://doi.org/10.1177/1363459320925863
Friedman, J., & Hansen, H. (2022). Evaluation of increases in drug overdose mortality rates in the US by race and ethnicity before and during the COVID-19 pandemic. JAMA Psychiatry. https://doi.org/10.1001/jamapsychiatry.2022.0004
Green, T. C., Case, P., Fiske, H., Baird, J., Cabral, S., Burstein, D., Schwartz, V., Potter, N., Walley, A. Y., & Bratberg, J. (2017). Perpetuating stigma or reducing risk? Perspectives from naloxone consumers and pharmacists on pharmacy-based naloxone in 2 states. Journal of the American Pharmacists Association, 57(2), S19-S27.e4. https://doi.org/10.1016/j.japh.2017.01.013
Greene, J. (2018). Naloxone “moral hazard” debate pits economists against physicians. Annals of Emergency Medicine, 72(2), A13–A16. https://doi.org/10.1016/j.annemergmed.2018.05.020
James, K., & Jordan, A. (2018). The opioid crisis in Black communities. The Journal of Law, Medicine & Ethics, 46(2), 404–421. https://doi.org/10.1177/1073110518782949
Keyes, K. M., Hatzenbuehler, M. L., McLaughlin, K. A., Link, B., Olfson, M., Grant, B. F., & Hasin, D. (2010). Stigma and treatment for alcohol disorders in the United States. American Journal of Epidemiology, 172(12), 1364–1372. https://doi.org/10.1093/aje/kwq304
Lett, E., Asabor, E., Beltrán, S., Cannon, A. M., & Arah, O. A. (2022). Conceptualizing, contextualizing, and operationalizing race in quantitative health sciences research. The Annals of Family Medicine, 20(2), 157–163. https://doi.org/10.1370/afm.2792
Minior, T., Galea, S., Stuber, J., Ahern, J., & Ompad, D. (2003). Racial differences in discrimination experiences and responses among minority substance users. Ethnicity & Disease, 13(4), 521–527.
Razaghizad, A., Windle, S. B., Filion, K. B., Gore, G., Kudrina, I., Paraskevopoulos, E., Kimmelman, J., Martel, M. O., & Eisenberg, M. J. (2021). The effect of overdose education and naloxone distribution: An umbrella review of systematic reviews. American Journal of Public Health, 111(8), e1–e12. https://doi.org/10.2105/ajph.2021.306306
Rostosky, S. S., Richardson, M. T., McCurry, S. K., & Riggle, E. D. B. (2022). LGBTQ individuals’ lived experiences of hypervigilance. Psychology of Sexual Orientation and Gender Diversity, 9(3), 358–369. https://doi.org/10.1037/sgd0000474
Semple, S. J., Grant, I., & Patterson, T. L. (2005). Utilization of drug treatment programs by methamphetamine users: The role of social stigma. The American Journal on Addictions, 14(4), 367–380. https://doi.org/10.1080/10550490591006924
Tobin, K., Edwards, C., Davey-Rothwell, M., & Latkin, C. (2018). Awareness and access to naloxone necessary but not sufficient: Examining gaps in the naloxone cascade. The International Journal on Drug Policy, 59, 94–97. https://doi.org/10.1016/j.drugpo.2018.07.003
Tsai, A. C., Kiang, M. V., Barnett, M. L., Beletsky, L., Keyes, K. M., McGinty, E. E., Smith, L. R., Strathdee, S. A., Wakeman, S. E., & Venkataramani, A. S. (2019). Stigma as a fundamental hindrance to the United States opioid overdose crisis response. PLOS Medicine, 16(11), e1002969. https://doi.org/10.1371/journal.pmed.1002969