Our study revealed that people with a history of opioid use indicated broad support for a variety of devices with harm reducing capabilities. The broadest support was shown for devices with the least specific interventional functionality, such as those that monitor vital signs, sense opioid overdose, call medical authorities, and/or act as a medical ID indicating the wearer is at risk of overdose. Additionally, participants maintained interest in a device that could itself sense an opioid overdose and administer naloxone to reverse the overdose. In contrast, devices relying on bystander intervention were the least supported solutions, despite the fact that the only currently available response to opioid overdose relies on others in the immediate vicinity. The results suggest that people with a history of opioid use show a strong desire and willingness to use device-based harm reduction solutions that limit morbidity and mortality of overdose as well as reduce the need for bystander intervention.
While willingness to use a device that could sense and reverse opioid overdose was strong, form factor was an important consideration. Configurations such as a cannula and glasses were strongly disfavored while configurations such as a watch-appearing bracelet were highly favored. A minority of our sample population found a device like this likely to be stolen or lost, citing the device’s ‘street value’– that is, the perceived cost to end-users – as the most important factor that would determine whether it would be stolen. Similarly by free response, device obscurity was deemed an essential aspect to users; any device deemed too conspicuous was unacceptable. Concerns over privacy was further highlighted by many participants’ fear of suspicion from law enforcement regarding a device placed underneath clothing being mistaken for contraband. The negative attitudes expressed towards police, likely born out of personal experiences of the participants, is noteworthy given the positive role police officers can play in promoting naloxone availability and treatment referral for opioid-using populations.19,20 In addition, many participants also expressed comfort as another driving consideration. We believe addressing the identified user preferences will be crucial to the adoption of such a device amongst this population.
Collectively, the study supports the overall concept that people with OUD are willing to use a device that both senses and reverses opioid overdose. Such a device would address unmet needs for harm reduction by mitigating the long-term effects of opioid overdose and preventing fatal overdose, particularly among those who use alone.10–13 While participants overwhelmingly identified a need for such a device among “anyone who uses opioids,” certain subgroups were identified as having greater need, such as people who are experiencing homelessness or those with low tolerance after periods of abstinence (e.g. return to use after leaving rehabilitation centers, medication assisted treatment, prison, or jail). However, this finding was inconsistent with a previous quantitative study that indicated that homelessness was negatively associated with willingness to wear a device to detect opioid overdose and alert bystanders.21 We suspect the discrepancy may relate to our observation that some participants were distrustful of bystanders who may take advantage of their unconscious state during overdose, and thus preferred a closed-loop system. Populations experiencing homelessness and other high-need populations represent logical first beneficiaries of future distribution strategies. As fentanyl and other powerful synthetic opioids continue to spread through our communities, the need for a device that can quickly detect and respond to an opioid overdose will become even greater.
Efforts to distribute current overdose reversal options – including generic naloxone intramuscular injection, an auto-injectable intramuscular naloxone in the form of Evzio®, and intranasal naloxone in the form of Narcan® – have been remarkably successful.22,23 Reliable methods to detect opioid overdoses and expand bystander intervention as well as strategies to address the high proportion of fatal overdose among people who use alone remain an open question. Technical feasibility remains a significant concern, as the development of algorithmic approaches to reliably detect opioid overdoses, by monitoring blood oxygenation and motion activity for example, is a complicated task that must consider numerous possible sources of physiologic noise. Mechanisms for delivery of small-volume drug solutions, such as naloxone, through wearable devices must also be further explored. This study data can be used to guide solutions to the identified technical challenges, with particular attention to the importance of a discreet device.
There were limitations to our study. Our sample represents a population of people using opioids in an urban setting with one of the most extensive naloxone distribution efforts in the United States, with hundreds of thousands of Narcan kits distributed in the past few years.24 This may have influenced the perception our study sample had of the need for the devices we proposed and limit generalizability of our findings. Additionally, the vast majority of our respondents were either experiencing housing insecurity while the majority of fatal overdoses in Philadelphia occur amongst individuals in their own homes.15 Furthermore, while the data were collected during the COVID-19 pandemic as overdoses rose rapidly among changing demographic groups, the potential effects of the pandemic on attitudes towards new overdose reversal interventions and propensity for high-risk drug use behaviors were not captured in the scope of our questions. 5,15,25 Unaccounted recent stressors, such as the need for social distancing considerations and mental wellness strain due to the COVID-19 pandemic may increase the rate of solitary opioid use, as well as increase the rates of return to use from settings providing Medication for Opioid Use Disorder (MOUD).5,15,25 Future directions include surveys of populations that more broadly represents those at highest risk of overdose as well as deeper exploration of form factor expectations.