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InterviewFindingsbyCategory:ExperienceswithNarcan

OPIOIDCONSUMERSIntervieweeswereaskedabouttheiraccesstoNarcan,aswellasexperiencesbeingadministeredand/oradministeringtheopioidantagonist.EmergentthemesallappeartobebarrierstoaccessanduseofNarcan.

Figure10.PerceivedBarrierstoAccessingNarcanAmongOpioidConsumers

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Lackofknowledgeand/orawarenesswasacommondenominatorformanyoftheinterviewees’commentsonthesubjectofaccesstoNarcan:

“Iwouldn’tevenknow[wheretofindit]”

“Youalwaysseeflyersaboutitbutyouhavetotraveltogetit”

“Yeah,whenIcametoGroupstheyaskedmeifIwantedtogetaprescriptionforNarcanbutIsaidnobecauseIknowIamnotgoingtooverdose…IwassogratefulforSuboxoneandI’mnotgoingtooverdose.Plus,Inevershotupmypills”

“Idon’tknowifpeopleactivelygoandtryandacquireit…I’mnotsureifyouneedaprescription…I’venevertriedtoacquireitmyself”

TheseconsumerquotesarerepresentativeofapervasivelackofknowledgeabouthowtoaccessNarcan,lackofknowledgeaboutindicationsfortheuseofNarcan,lackofawarenessoflawsonwidespreadstandingorders(openscript)atpharmaciesacrossNewHampshire,andlackofinterest.

Levelsofknowledgeaboutaccessvariedbuttherewasapervasivesensethatconsumersdon’twantorneedit.Perceivedcostscombinedwithafalsesenseofsecurityposeasignificantbarriertoaccessformany:“‘Nobodythinksthey’regonnaOD…Nobodyisgonnaspend$50bucks,especiallyiftheyhaveaproblem[opioidaddiction].’‘Itdoesn’tseemlikethey’reaffordableunlessyougetitforfreefromanoutreachcenter.It’snothighonyourprioritytogotoaplacelikethatwhenyougotstuffthatyougottodo.Thatandyoudon’twantsomeoneNarcanningyouwhenyoudon’tthinkthatyouneeditbecauseitfeelsreallyhorrible.’”

Thislattersentimentintroducesanotheroften-citedbarrier,namelythatthephysicalsideeffects(e.g.withdrawal)fromNarcanthatsomehaveexperienced,andthatallseeminglyhaveheardabout,aretobeavoidedatallcosts.WhenaskedaboutsideeffectsofNarcanadministration,itbecameclearthatconsumersunderstandhowNarcanworks–itactsquicklytodisplacetheopioidsfromtheopioidreceptorsinthebrainandinsodoing,precipitatesnearimmediatewithdrawalsymptoms.

Itiswellknownthatpeopledependentonopioidswillcontinuetouseopioidsdespiteseverenegativeconsequencessimplytoavoidbecomingsickorgoingintofullopioidwithdrawal.Thus,itisunsurprisingthatconsumersdescribethephysicalsideeffectsofbeingadministeredNarcaninthefollowinghighlydescriptive,vividways:“[Youfeel]fuckingmiserableandhatewhoeverdiditto[you]”and“TheonlyeffectsI’vewitnessedafteryouuseitisthepersonisinstantly

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sick.Thethingisoncethey’reininstantwithdrawals,thefirstthingthey’regoingtodowhentheyleavethehospitalisthey’regoingtogooutandfindsomeherointomakethemselvesfeelbetter…I’vealwaystoldpeoplethatifIwasOD’ing,tryandgetmetocomebackontheirownandworstcaseuseNarcanbutIdon’twantitusedonme.”ThisquotesummedupwhyNarcanisaversivetomany–itcausesimmediatewithdrawal.Therefore,itiscommonforconsumerswhohavebeenadministeredNarcantouseopioidswithinhoursoftheirreversals.“It’ssadbutit’swhattheydo.”Nootherphysicalsideeffectswerenotedbyconsumers.

PerceivedstigmaisanotherbarriertoaccessingNarcan.Oneconsumersaidthathe“hear[s]thatnowinNHtheyaretryingtohaveanopenprescriptionatthepharmacyandIhaveaproblemwiththepharmacything…alotofusersdon’ttrustthepharmacies…itslegalbutmoststoresarenotparticipating.”AnotherconsumerthoughtthatyoucangotothepolicestationorthefirestationorahospitaltogetNarcanif“youwantitfortherightreason,”buthedoesn’t“thinktheywouldgiveittoastrung-outaddictwhoisjustgonnaoverdoseandtryandbringhimselfback.”AndyetanotherconsumeracknowledgesthathestolehisNarcankitsohedoesn’t“knowhownormalpeoplegetthisshit.”Thesensethatpharmaciesarechoosingnottoparticipateintheopenprescriptionmovement,thatonemightnotbeworthyofakit,orthatconsumersarenot“normal”allpointtotheperceivedstigmatizationofthispopulationandhowitimpactsaccesstoandtheuseofNarcan.

Fearofthepolice,aresultofalackofconfidenceinthegoodfaithapplicationoftheGoodSamaritanlaw,isanotheridentifiedobstacle.Forexample,oneyoungmansaid,“Ithinkpeoplesayitandit’slikenobodybelievesit[GoodSamaritanLaw].Somebodysays,‘Ohyoucancall,youwon’tgetintrouble’andpeoplearelike‘Dudeyou’refuckingdumb.I’mnotcalling’.’’

OnefinaldeterrenttowidespreadaccessanduseofNarcanistheragethatsomepeoplesuggestconsumersexpresstothefirstrespondersand/orfriendswhoadministerNarcanafteranoverdose.Exemplifyingthissentiment,oneconsumersaid,“Youarepissed.PrettymucheverytimeI’veoverdosed,andeverybodythatIknowhasoverdosed,hassaid,‘Iwasn’toverdosing.Iwasjustreallyhigh,andyouruinedit.’Butthentheparamedic’stheresaying,‘No,no,youweredead.’”Notably,justunderhalfofthisconsumersubsamplehadpersonalexperiencewithNarcan,thoughmanyofthoseinthiscategoryhavewitnesseditsadministrationonfriendsorfamily.

FIRSTRESPONDERSANDEMERGENCYDEPARTMENTPERSONNELR/EDpersonnelwereaskedseveralquestionsaboutNarcan.Therewasaprevalentsenseofamazementamongrespondersatthelife-savingeffectsofNarcan(e.g.,“Ifthere’sanymiracledrugoutthereforthattypeincident,that’sit”(Fire).)However,manyR/EDpersonnelwere

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quicktonotethatNarcan“‘isashort-termfix,unfortunately,foraverylong-termproblem”(EMS);“Ithinkit’sanecessaryevil.Imean,plainandsimple,itsaveslivesandIthinknobodywantstoseeanotherhumanbeingdie”(EMS).

SomerespondersfearedthatthepublichasmisconceptionsaboutNarcangiventhatpatientsaresometimesbeyondthepointofrevival:“IcoulddumpagallonofNarcanintothemandit’snotgoingtowakethemup,andhavethefamilywonderwhy.Narcanhasbeenbilledasamiracledrugbypoliticians,andbureaucrats,andsocalledexperts.Whenthetimingisright,itisamiracledrug.However,itdoesn’thelpeverybody”(EMS).OneresponderwantedtobesurethatthosewhoareunfamiliarwithNarcanunderstandthatpeoplewhoareoverdosingareunabletogiveNarcantothemselves.AnotherexplainedthatthereversaleffectsofNarcancanwearoffquicklyandsendthepatientbackintoanoverdose.

R/EDpersonnelalsohadmixedviewpointsaboutwhetheradministeringNarcanintravenouslyorintranasallyissaferandmoreeffective.Whilesomebelievethatintravenousadministrationallowsproviderstobe“alotmorenuancedinhowweuseNarcan,sowe’velearnedtotailoritto,really,justtheirrespiratorydriveasopposedtohavingthembebothwideawakesittingupright,staringatyouinwithdrawal”(ED),othersbelievethatintranasaladministrationissaferforbothpatientsandproviders,aslongasproviderswaitasufficientamountoftimeafteradministeringeachdose.

“WhenyougaveanIV,ifyouadministeredittoofast,peoplewouldwakeupinstantly.Theywouldbeincrediblyviolentandangry,sonowyouhaveanangry,combativepatientandacontaminatedsharpneedleinthebackofaverysmallambulance,andthatposedahugeriskforus.Now,beingabletogiveitintranasallyismuchsaferforadministeringit.Theproblemwithitisthatitdefinitelytakesmuchlongertobeabsorbedintothebloodstream,andEMSprofessionalsandhealthcareproviderstendtonotbethatpatient.Whatusedtotake30seconds,maybe60secondstowork,sometimescantake5,maybeevenafull10minutebeforeitfullywakesthepatientup.Peoplebecomeimpatient,sotheygivemoreofit.Nextthingyouknow,youwakethepatientuptooquicklyandthey’recombativeandtheywannatearyourheadoff.ButintranasallyisamuchsaferrouteforadministeringNarcan.”(EMS)

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ThevastmajorityofR/EDpersonnelreportednounanticipatedsideeffectscausedbyNarcan.TherewasoneaccountofaNarcanadministrationresultinginanosebleedduetoimproperadministrationbyalaypersonwhoforgottoattachtheatomizer.Additionally,oneEDprovidercitedpulmonaryedemaasaknownsideeffectbutexplaineditiscausedbyadministeringtoomuchNarcanorgivingittooquickly.R/EDpersonnelhadneverheardofbraindamageasaresultofNarcanadministrationandconjecturedthatanyreportsofbraindamage“couldhavebeencausedbylackofoxygentothebrainpriortotheadministration[ofNarcan]”(Fire).WhilewithdrawalsymptomsareapotentiallyanticipatedeffectofNarcan,R/EDpersonnelexplainedthatthesesymptomscanbeattenuatedthroughcarefuladministration:“Ifyougiveitniceandslow,youcangettheexacteffectyouwant,butyoujustneedtobemindfulaboutthat”(Fire).

R/EDpersonnelreportedthattheavailabilityofNarcanhasincreasedincommunities:“It’ssoeasy,there’ssomuchNarcanoutthere.Everybody’sgivingitout”(Fire).OneEMSproviderdiscussedaprograminwhichheandhisteam“actuallydistributeNarcanouttothepreviousoverdosesthatwehaveintown”(EMS).However,R/EDpersonnelhadconflictingopinionsregardingwhetherthepublicshouldhaveaccesstoNarcan.Somebelievedthatpublicavailabilityisbeneficial:“Itcanappropriatelybeinplaceswhereaddictionoverdosesareknowntoincur.Thatincludesprivatehomes,orpartyareas”(ED).OthersthoughtthatmakingNarcanavailabletolaypeopleiscounterproductive:“Makingitmorewidelyavailable,they’reonlylivingtouseanotherday,asopposedtochangingthelifestyleorthebehaviorsthatareleadingthemtouse.Ithinkthatactuallywillatsomepointbecontributingtotheproblemandnotmakingitbetter”(Fire).

TherewasgreaterconsensusthatrespondersshouldcarryNarcan.“Inthemedicalsettingitisanessentialdrug.Ilikeitinthehandsofallfirstresponders,includingpolice,andfire,andEMS”(ED).However,oneresponderexpressedconcernsthatsomemedicalprofessionalsmayneedmoreeducationtoknowthatadministeringNarcanisonlyappropriateforopioidoverdosesandnotforothertypesofoverdoses.

SeveralpotentialunintendednegativeconsequenceswerenotedasaresultofNarcan’savailabilityincommunities.AfewR/EDpersonnelhadheardof“Narcparties”or“Lazarusparties,”inwhichpeopleuseNarcanwithasoberfriendsothattheycanusemoreorahigherpotencyofanopioid.OthersbelievedthatconsumerswhohavebeengivenNarcanbyabystandermaynotseekprofessionaltreatment.ManyR/EDpersonnelalsoworriedthatNarcanmaygiveafalsesenseof

“IthinkthebadsideisIdon’tthinkwe’recalledasmuchnow.Ithinkthey’rejustusingtheNarcanandthenjustsaying,‘Wedon’twantthepoliceortheEMSthere.’”(EMS)

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security:“IammindfulthatwhenapatientwhohasopiateaddictiondisorderpossessesNarcan,theysometimesmakeacognitivemistakethinking,‘Well,Iwillbeabletosurviveevenanoverdose,soIcanreallypushmyhighrighttotheedge.’Thatisfoolishthinkingcausedbytheiraddiction,anditcankillthem”(ED).OnerespondernotedthereissomuchNarcanavailablethat“wedon’tevenknowtheextentoftheoverdosesanymore”(Fire).AnotherresponderspeculatedthatNarcanisover-utilized,claimingthat“peoplehearoverdose,andthefirstthingtheywanttodoisgiveNarcan”(Fire).

SUMMARYOverwhelmingly,opioidconsumersreportsignificantbarrierstoaccessingandusingNarcaninNewHampshire,includinghighcosts,fearofpolice,fearofstigmatization,lackofknowledge(e.g.,access,indicationsandlaws),andfearofsideeffects.Sideeffects,notablywithdrawalandangerassociatedwithwithdrawal,wereadeterrentfromwantingNarcanadministeredduringanoverdose.

Conversely,R/EDpersonnelstateNarcaniswidelyavailableandalifesavingmedication.Althoughtherearemixedbeliefsonwhetheritshouldbeavailabletothepublic,therewasconsensusthatrespondersshouldcarryit.R/EDpersonnelalsosharedmixedrecommendationsonwhetheritissaferormoreeffectiveadministeredintravenouslyorintranasally,butagreedthatsideeffectsbeyondangerassociatedwithwithdrawalhavenotbeenobserved.