For new members of 12-step programs like Alcoholics Anonymous and Narcotics Anonymous, naloxone can still seem like a symbol of drug use, according to new research. This can cause some people looking to kick drugs through these large abstinence-based fellowships—NA, for example, holds 70,000 weekly meetings in 144 countries, according to a 2018 survey—to decline to carry the overdose-reversal drug, seeing it as a relic of a past life.
But as fentanyl and its analogs continue to adulterate drug supplies around the world, it’s important that this demographic recognizes that naloxone, a vital tool in preventing overdose deaths, needn’t be associated with personal drug consumption, said Jeanette Bowles, one of the new paper’s authors.
“It’s about rescuing peers. It’s about the possibility that others that they know could resume drug use,” Bowles—who is also a postdoctoral fellow with the Centre on Drug Policy Evaluation at St. Michael’s Hospital in Toronto—told Filter.
The research, recently published in the International Journal of Drug Policy, came out of a larger study that began in 2018. Bowles and her team were studying 348 individuals in southern California who had used opioids in the last month. As part of the work, they offered participants naloxone to take home, in case they needed to reverse an overdose.
However, one demographic declined to take the naloxone notably often: People who had recently joined, or rejoined, 12-step programs.
The researchers decided to investigate further, to get a sense of why this group reacted this way. So they carried out interviews with 44 respondents with treatment experience, some of whom were in the early stages of abstinence.
Through this qualitative approach, the researchers found a number of common rationales among the respondents. Some felt that, as they were in 12-step programs, they would not be in a position to witness an overdose. Another common reason was people feeling that if they carried naloxone, they might end up being around people who used drugs again—and they wanted to end that chapter of their lives. Naloxone was, in some cases, considered a “symbol of ongoing drug use,” Bowles told Filter.
Another element was that, if the people in the 12-step programs liked their peers, they could end up seeking social acceptance by following certain expectations within the group.
A former member of a 12-step program, who asked to be referred to as “Kate,” offered some insight into this mindset through her own experiences.
“Twelve-step programs require total commitment to abstinence, and stress staying away from ‘people, places and things’ that remind you of drug use,” Kate told Filter. “Carrying naloxone—unless you are an emergency medical professional—would make no sense in this context, as you’ve committed to avoiding the possibility of being around people who might overdose. There’s also a deep cultural opposition to anything that could be considered ‘enabling.’”
“We don’t want naloxone to be a thing that is symbolic of drug use, but rather that it becomes a symbol of life-saving.”
It’s possible that the 44 respondents in Bowles’ study may have lumped naloxone in with the “people, places and things” that 12-step culture warns about. “We don’t want naloxone to be a thing that is symbolic of drug use, but rather that it becomes a symbol of life-saving,” Bowles said.
When a person who uses drugs adheres to an abstinence-based program, their tolerance to their drug they were using inevitably decreases. This—in combination with a market full of drugs of an increasingly potent and unpredictable nature—means that a person in a 12-step program would be at increased risk of an opioid-involved overdose if they returned to using drugs.
Bowles’ team learned of an instance in which a group of people who formerly used drugs met at a treatment center, then ended up going to a hotel room to use drugs again together. However, because they were together and had been given naloxone by the treatment center, they were able to reverse the overdoses that occurred.
A spokesperson for NA World Services told Filter in an email that the organization follows a set of Twelve Traditions. The 10th of them states: “Narcotics Anonymous has no opinion on outside issues; hence, the NA name ought never be drawn into public controversy.”
“Given that tradition, we have no opinion on naloxone,” the email read.
It’s important to be clear that an unwillingness to carry naloxone is by no means exclusive to people in 12-step programs. According to a paper released in December, people who use opioids may know how to administer the lifesaving drug, and may own it, but some still don’t carry it with them in their daily lives. In this study, the team interviewed 20 people who used illicit opioids.
According to Alex Bennett, a researcher at the department of social and behavioral sciences at New York University’s School of Global Public Health, The respondents outlined a few barriers to regularly carrying and administering naloxone.
“You have this stigma that’s very pervasive across society.”
One reason was indifference. But some respondents also thought that carrying naloxone might identify them as people who use drugs—and they did not want the stigma associated with that. “You have this stigma that’s very pervasive across society,” Bennett said.
Some respondents were also worried that carrying naloxone would draw police attention—a fear that’s rooted in reality in some jurisdictions. Others worried about mistakenly administering naloxone, for example to a person who may appear to be overdosing but is not. Doing so could bring about withdrawal, as the medicine effectively blocks the action of the opioids within a person’s system. But of course, this risk pales in comparison to the risk of not giving naloxone to a person who is overdosing.
To further outline this issue, an as-yet unreleased companion piece to this research saw the researchers gather quantitative data about 576 participants, all of whom use illicit opioids. The researchers found that 66 percent of respondents had received overdose prevention training, and around 80 percent of them owned naloxone. But, around 65 percent said that naloxone was not on hand for them while they were using opioids, Bennett said.
The researcher also emphasized how important it is—including for those who aren’t opioid users, given the adulteration of other supplies—that people not only obtain naloxone, but also keep it on them and know how to use it.
According to Frances Fu, Drug Overdose Prevention Education’s (DOPE) project manager, it’s entirely understandable for a person to not want to carry something if they are concerned with stigmatization or criminalization—or indeed, if they feel that it might inhibit the changes that they want to make in their own lives.
At the same time, she noted that a person carrying naloxone doesn’t mean that they use drugs. She also made the case for people in the recovery community to view naloxone as just something to have on-hand in case of emergencies—and for mutual understanding between the recovery and harm reduction philosophies.
“On an individual level, harm reduction also holds abstinence as a valid strategy in reducing harms. It’s where that person, that individual person, is at at that moment,” Fu told Filter. “I think harm reduction as a movement is about holding contradictions.”
Jake Arther, American Addiction Centers‘ outreach coordinator for the state of Oklahoma, himself quit opioids nearly eight years ago. Naloxone is a valuable tool, but one that also might be triggering for some people in recovery, he told Filter. “A needle could be a trigger for them,” he added, while noting that nasal naloxone spray, which avoids this potential drawback, is becoming more common. “It definitely depends on the person and situation.”
From personal experience, Arthur said that carrying naloxone might not be as prevalent among people in 12-step programs, though he has seen many who do—particularly among those who take more active and outreach roles in such communities.
Experts believe that more effective messaging to this community can improve upon the naloxone uptake that already exists.
As Arthur noted, many rehabs and other recovery facilities in the United States do hand out naloxone. According to an email from Lawrence Weinstein, chief medical officer of the American Addiction Centers organization, “the vast majority of facilities that interact with people in recovery … have naloxone at the ready.”
Even as the recent research into 12-step members and naloxone offers grounds for concern, experts believe that more effective messaging to this community can improve upon the naloxone uptake that already exists.
“From a public health perspective, it’s critical we look at [how to] reframe the meaning of naloxone,” Bowles said, “so it isn’t about a reminder of ongoing drug use, but rather a commitment to the community safety net.”