Take-Home Naloxone and risk management among people who survived an opioid overdose; a qualitative analysis informed by drug, set and setting

Background: Sweden has one of the highest rates of overdose mortality in Europe. Take-Home-Naloxone programs were introduced nationwide in 2018. This qualitative study builds on international research that has expanded a previously narrow, medical focus on overdose deaths, exploring the role of naloxone among overdose survivors in a context of severe stigmatization of people who inject drugs (PWID).

Methods: The study uses Zinberg’s theoretical framework to look beyond the role of the drug in order to include the attitudes and personality of the person (set) and contextual factors (setting). Face to face semi-structured interviews were conducted with 22 individuals who had survived an opioid overdose, recruited from the clients of the Stockholm needle exchange. All participants had received naloxone in an overdose situation, usually from a peer (though sometimes self-administered). The interviews were processed through thematic analysis using deductive and inductive coding.

Results: Interviewees represented both genders and a mix of drug use (opioids and stimulants). Participants described an everyday existence characterized by uncertainty, stress and social exclusion. While most participants attributed their latest opioid overdose to drug, many shared narratives of hopelessness leading to increased risk taking, acknowledging set as a contributing factor to overdoses. A stressful setting directly caused some overdoses, with public drug use frequently reported. Though PWID have incorporated Take-Home-Naloxone into their practices of handling overdose emergencies, they also reported controversial actions such as administering stimulants. Most participants denied firmly that the presence of naloxone encouraged riskier behaviour. Despite harsh withdrawal symptoms accompanying naloxone revival, participants retained an overwhelmingly positive attitude towards naloxone.

Conclusion: The complex circumstances described in participants overdose reporting illustrate the intertwining effect of drug, set and setting. Harm reduction interventions focussed on individuals have to be accompanied by structural changes in order to lessen risks and reduce the incidence of overdose deaths.