Remaking the 'angry Narcanned subject': Affording new subject positions through take-home naloxone training

Naloxone is a medication used to reverse opioid overdose. Alongside its lifesaving effects, it also has a reputation for producing distress, aggression and occasionally violence upon administration. This article analyses how take-home naloxone (THN) training initiatives address naloxone's reputation for producing aggression and conflict, and how new subject positions emerge in the context of this training. While the role of naloxone in producing aggression has been discussed in a range of research, this work emphasises that such conflict is neither inevitable nor even likely because it is contingent on several other issues such as administration practices. Building on this scholarship, we work with Bruno Latour's theorisation of technological 'affordances' to analyse THN as a socially co-produced technology that, rather than either determining or neutrally communicating actions and effects, 'affords' possibilities, capacities and subjects. Analysing data drawn from observations of THN training in Victoria, Australia, and in-depth interviews with training participants, we argue that the issue of conflict upon revival affords a subject position we term the 'angry Narcanned subject'. This subject, we note, has come to hold a powerful position in understandings of naloxone, not least because it tends to accord with stereotypes of antisocial drug users. From here, we argue that a much of THN training is focused on challenging and reframing naloxone's reputation for conflict and questioning related subject positions, especially that of the angry Narcanned subject. We argue that this process of challenging and reframing affords two new subject positions for consumers: the 'capable administrator' and the 'calmer revivee'. We conclude that while THN training affords multiple, potentially positive, subject positions, unless these initiatives are accompanied by broader interventions such as decriminalisation campaigns, they may inadvertently responsibilise people who consume opioids for addressing overdose and erase the role of prohibition, criminalisation and stigmatisation in producing overdose events.

Exploring trauma and wellbeing of people who use drugs after witnessing overdose: A qualitative study

BACKGROUND

The national overdose crisis is often quantified by overdose deaths, but understanding the traumatic impact for those who witness and respond to overdoses can help elucidate mental health needs and opportunities for intervention for this population. Many who respond to overdoses are people who use drugs. This study adds to the literature on how people who use drugs qualitatively experience trauma resulting from witnessing and responding to overdose, through the lens of the Trauma-Informed Theory of Individual Health Behavior.

METHODS

We conducted 60-min semi-structured, in-depth phone interviews. Participants were recruited from six states and Washington, DC in March-April 2022. Participants included 17 individuals who witnessed overdose(s) during the COVID-19 pandemic. The interview guide was shaped by theories of trauma. The codebook was developed using a priori codes from the interview guide; inductive codes were added during content analysis. Transcripts were coded using ATLAS.ti.

RESULTS

A vast majority reported trauma from witnessing overdoses. Participants reported that the severity of trauma varied by contextual factors such as the closeness of the relationship to the person overdosing or whether the event was their first experience witnessing an overdose. Participants often described symptoms of trauma including rumination, guilt, and hypervigilance. Some reported normalization of witnessing overdoses due to how common overdoses were, while some acknowledged overdoses will never be "normal." The impacts of witnessing overdose on drug use behaviors varied from riskier substance use to increased motivation for treatment and safer drug use practices.

CONCLUSION

Recognizing the traumatic impact of witnessed overdoses is key to effectively addressing the full range of sequelae of the overdose crisis. Trauma-informed approaches should be central for service providers when they approach this subject with clients, with awareness of how normalization can reduce help-seeking behaviors and the need for psychological aftercare. We found increased motivation for behavior change after witnessing, which presents opportunity for intervention.

Opioid overdose reversals using naloxone in New York City by people who use opioids: Implications for public health and overdose harm reduction approaches from a qualitative study

BACKGROUND

Adverse reactions to naloxone, such as withdrawal symptoms and aggression, are widely recognised in the literature by pharmaceutical manufacturers and clinical practitioners as standard reactions of individuals who are physically dependent upon opioid drugs following the reversal of potentially fatal opioid overdose. This paper seeks to provide a differentiated view on reactions to naloxone that may have important implications for public health and harm reduction approaches.

METHODS

Analyses from a qualitative investigation embedded within a 5-year Randomised Controlled Trial (RCT) examined the risks and benefits of Overdose Education and Naloxone Distribution (OEND) training models (brief or extended training) in various populations of people who use opioids in New York City. The qualitative experiences (obtained through semi-structured interviews) of 46 people who use opioids and who were each involved in the delivery of naloxone, during 56 separate overdose events that occurred throughout 2016-2018, were studied. Situational analysis and inductive content analysis of interview data focused upon overdose reversals in an attempt to provide understandings of the various adverse effects associated with naloxone from their perspective. These analyses were supplemented by data sessions within the research team during which the findings obtained from situational analysis and inductive content analysis were reviewed and complemented by deductive (clinical) appraisals of the various physical and psychological effects associated with the overdose reversals.

RESULTS

People who use opioids recognise three distinct and interconnected outcomes that may follow a successful opioid overdose reversal after intramuscular or intranasal administration of naloxone. These outcomes are here termed, (i) 'rage' (describing a wide range of angry, hostile and/or aggressive outbursts), (ii) 'withdrawal symptoms,' and (iii) 'not rage, not withdrawal' (i.e., a wide range of short-lived, 'harmless' conditions (such as temporary amnesia, mild emotional outbursts, or physical discomfort) that do not include rage or withdrawal symptoms).

CONCLUSION

Physical and psychological reactions to naloxone should not be understood exclusively as a consequence of acute, opioid-related, withdrawal symptoms. The three distinct and interconnected reversal outcomes identified in this study are considered from a harm reduction policy perspective and are further framed by concepts associated with 'mediated toxicity' (i.e., harm triggered by medicine). The overall conclusion is that harm reduction training programmes that are aligned to the policy and practice of take home naloxone may be strengthened by including awareness and training in how to best respond to 'rage' associated with overdose reversal following naloxone administration by people who use opioids and other laypersons.

Development of a proto-typology of opiate overdose onset

BACKGROUND AND AIMS

The time available to act is a crucial factor affecting the probable success of interventions to manage opiate overdose. We analyse opiate users' accounts of non-fatal overdose incidents to (i) construct a proto-typology of non-fatal opiate overdose onset and (ii) assess the implications for overdose management and prevention of fatalities.

METHODS

Re-analysis of a subset of data from a large qualitative study of non-fatal opiate overdose conducted from 1997 to 1999. Data were generated from semi-structured interviews undertaken with opiate users who had experienced a non-fatal overdose in the previous 24 hours. Forty-four participants (30 men; 14 women; aged 16-47 years) provided sufficient information for in-depth analysis. Data relating to 'memory of the moment of overdose', 'time to loss of consciousness' and 'subjective description of the overdose experience' were scrutinised using iterative categorization.

FINDINGS

Four types of overdose onset were identified: type A 'amnesic' (n = 8), characterized by no memory, rapid loss of consciousness and no description of the overdose experience; type B 'conscious' (n = 17), characterized by some memory, sustained consciousness and a description of the overdose in terms of feeling unwell and symptomatic; type C 'instant' (n = 14), characterized by some memory, immediate loss of consciousness and no description of the overdose experience; and type D 'enjoyable' (n = 5), characterized by some memory, rapid loss of consciousness and a description of the overdose experience as pleasant or positive.

CONCLUSIONS

The identification of different types of overdose onset highlights the complexity of overdose events, the need for a range of interventions and the challenges faced in managing incidents and preventing fatalities. Opiate overdose victims who retain consciousness for a sustained period and recognize the negative signs and symptoms of overdosing could summon help or self-administer naloxone, thus indicating that opiate overdose training should incorporate self-management strategies.

Iterative categorization (IC): a systematic technique for analysing qualitative data

The processes of analysing qualitative data, particularly the stage between coding and publication, are often vague and/or poorly explained within addiction science and research more broadly. A simple but rigorous and transparent technique for analysing qualitative textual data, developed within the field of addiction, is described. The technique, iterative categorization (IC), is suitable for use with inductive and deductive codes and can support a range of common analytical approaches, e.g. thematic analysis, Framework, constant comparison, analytical induction, content analysis, conversational analysis, discourse analysis, interpretative phenomenological analysis and narrative analysis. Once the data have been coded, the only software required is a standard word processing package. Worked examples are provided.

Naloxone--does over-antagonism matter? Evidence of iatrogenic harm after emergency treatment of heroin/opioid overdose

AIM

To analyse drug users' views and experiences of naloxone during emergency resuscitation after illicit opiate overdose to identify (i) any evidence of harm caused by excessive naloxone dosing ('over-antagonism'); and (ii) implications for the medical administration of naloxone within contemporary emergency settings.

DESIGN

Re-analysis of a large qualitative data set comprising 70 face-to-face interviews conducted within a few hours of heroin/opioid overdose occurring, observations from hospital settings and a further 130 interviews with illicit opiate users. Data were generated between 1997 and 1999.

SETTING

Emergency departments, drug services and pharmacies in two Scottish cities.

PARTICIPANTS

Two hundred illicit opiate users: 131 males and 69 females.

FINDINGS

Participants had limited knowledge of naloxone and its pharmacology, yet described it routinely in negative terms and were critical of its medical administration. In particular, they complained that naloxone induced acute withdrawal symptoms, causing patients to refuse treatment, become aggressive, discharge themselves from hospital and take additional street drugs to counter the naloxone effects. Participants believed that hospital staff should administer naloxone selectively and cautiously, and prescribe counter-naloxone medication if dosing precipitated withdrawals. In contrast, observational data indicated that participants did not always know that they had received naloxone and hospital doctors did not necessarily administer it incautiously.

CONCLUSIONS

Opiate users in urban Scotland repeatedly report harm caused by naloxone over-antagonism, although this is not evident in observational data. The concept of contemporary legend (a form of folklore that can be based on fact and provides a means of communicating and negotiating anxiety) helps to explain why naloxone has such a feared reputation among opiate users.

Characteristics of drug users who witness many overdoses: implications for overdose prevention

BACKGROUND

Programs to improve response of drug users when witnessing an overdose can reduce overdose mortality. Characteristics of drug users may be associated with the number of overdoses ever witnessed. This information could inform overdose prevention programs.

METHODS

Participants in New York City, who were age 18 and older with heroin and/or cocaine use in the past two months, were administered structured interviews (n=1184). Survey topics included overdose response, drug use behavior, treatment history, and demographic information.

RESULTS

In a multivariable negative binomial regression model, those persons who were male (IRR [Incidence Rate Ratio]=1.7, CI [95% Confidence Interval]=1.4,2.2), had experienced homelessness (IRR=1.9, CI=1.4,2.6), had used heroin (IRR=2.0, CI=1.3,3.2), had overdosed themselves (IRR=1.9, CI=1.6,2.4), or had attended Narcotics Anonymous (IRR=1.3, CI=1.1,1.6) witnessed a greater count of overdoses in their lifetime. Those persons who have witnessed more overdoses were less likely to have sought medical assistance (OR [Odds Ratio]=0.7) and more likely to report counter-productive or ineffective actions (ORs between 1.9 and 2.4) at the last overdose they witnessed compared to persons who had only ever witnessed one or two overdoses.

CONCLUSIONS

Persons at high risk for overdose are likely to witness more overdoses. Persons who had witnessed more overdoses were more likely to report taking ineffective action at the last overdose witnessed. Individuals who have witnessed many overdoses are likely key targets of overdose response training.

Recent life problems and non-fatal overdose among heroin users entering treatment

AIMS

To investigate the role of recent life problems in non-fatal overdose among heroin users entering various drug treatment settings.

DESIGN

Cross-sectional data from a longitudinal study investigating drug treatment effectiveness.

SETTING

Five prison drug treatment services, three residential rehabilitation units, three residential detoxification units and 21 community drug treatment services located in rural, urban and inner-city areas of Scotland.

PARTICIPANTS

Of a total of 793 primary heroin users commencing drug treatment during 2001-02, 337 (42.5%) were prison drug service clients; 91 (11.5%) were residential rehabilitation clients; 97 (12.2%) were residential detoxification clients; and 268 (33.8%) were community drug treatment clients.

MEASUREMENTS

Univariate and stepwise multivariate logistic regression analyses examined associations between overdosing in the 90 days prior to treatment entry and basic demographic characteristics, recent drug use and recent life problems.

FINDINGS

Ninety-one study participants (11.5%) reported at least one overdose and 19 (2.4%) reported more than one overdose in the 90 days prior to treatment entry. A chi2 test revealed no significant difference in rates of recent overdosing between the four treatment settings (P = 0.650). Recent drug use and recent life problems-but not demographic characteristics-were associated independently with recent overdosing. However, recent life problems were not associated independently with recent overdosing among clients entering prison, clients entering residential rehabilitation or with multiple recent overdosing.

CONCLUSIONS

Associations between recent life problems and recent overdose were evident, but varied by treatment setting. Treatment providers should identify and address heroin users' life problems as part of a broad strategy of overdose prevention.