A novel naloxone distribution intervention among persons experiencing unsheltered homelessness: Acceptability of naloxone training and distribution during an annual Point-in-Time Count

doi:10.21203/rs.3.rs-4720126/v1

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Research Article

A novel naloxone distribution intervention among persons experiencing unsheltered homelessness: Acceptability of naloxone training and distribution during an annual Point-in-Time Count

https://doi.org/10.21203/rs.3.rs-4720126/v1

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Background

The United States is experiencing an intersecting crisis of structural inequities driving unprecedented rates of homelessness and the fourth wave of the opioid epidemic. Consequently, persons experiencing homelessness are at increased risk of dying from opioid related fatalities. While naloxone engagement is crucial to mitigating opioid related mortality, persons experiencing homelessness encounter structural barriers to obtaining and retaining naloxone. The main purpose of this study was to explore the acceptability of a novel overdose management training and naloxone distribution effort during an annual Point-in-Time (PIT) unsheltered count.

Methods

The distribution of naloxone kits was tracked, and PIT Count volunteers were recruited via convenience sampling for an electronic postintervention survey to assess the intervention’s acceptability. Descriptive statistics were performed to explore volunteer’s perceptions of acceptability, based on the Theoretical Framework of Acceptability, for both the overdose management training and naloxone distribution efforts during the PIT Count.

Results

Results revealed a high level of acceptability for both the overdose management training and naloxone distribution efforts among volunteers during the PIT Count.

Conclusions

Results highlight that naloxone distribution during the PIT Count was generally acceptable to PIT Count volunteers. These findings have significant implications for the adoption of naloxone distribution efforts during PIT Counts throughout the United States to increase naloxone engagement and reduce opioid related mortality among persons experiencing homelessness and provide a foundation for future effectiveness studies.

Naloxone

opioid overdose

persons experiencing unsheltered homelessness

point in time count

opioid mortality

acceptability

overdose education and naloxone distribution

While over 1 million people in the United States have died as a result of preventable fatal drug overdoses,(1) persons experiencing homelessness (PEH) are over 30 times more likely to die of a fatal drug overdose than the general population.(2) Moreover, racial disparities in homelessness (3) and opioid-related overdoses (4, 5) are reflected in the acceleration of fatal drug overdoses among Black and Latine people experiencing homelessness compared to their White counterparts.(3) Nationally, over 650,000 reported experiencing homelessness with 39.3% of these individuals experiencing unsheltered homelessness during the single point-in-time (PIT) count conducted across the country in January 2023.(6) In 2022, California accounted for 28% of the nation’s unhoused population, totaling to over 181,000 unhoused individuals, and almost one-half (49%) of the nation’s unsheltered population.(7) Furthermore, over two-thirds (68%) of PEH in California were unsheltered – over 123,000 individuals.(7)

Recent studies have shown that access to naloxone, a safe and effective FDA-approved over the counter medication for reversing opioid overdoses, is associated with a 14% decrease in opioid overdoses in the general population and a 23% decrease among Black Americans.(8) Therefore, naloxone engagement and re-engagement with people who use drugs (PWUDs) and who are experiencing homelessness serves as a vital component in the strategy to mitigate opioid-related overdose morbidity and mortality in this population. In addition to syringe service programs, recent strategies implemented to increase access to naloxone and reduce opioid fatalities among PEH in Los Angeles County, include street outreach and distribution, secondary distribution to community groups and county agencies, and setting up naloxone vending machines in the county jails.(9) While overdose deaths remained the leading cause of death for PEH in Los Angeles County, these efforts to increase access to naloxone prevented the death rate from opioid related overdoses from increasing among persons experiencing unsheltered homelessness (PEUH) in the County in 2022.(9) Unfortunately, the opioid mortality rate among Black people experiencing homelessness continued to significantly increase in Los Angeles County in 2022,(9) which aligns with previous findings that Black people who inject drugs are less likely to receive naloxone compared to their White counterparts.(10)

Despite the rising opioid fatality rates and the efficacy of naloxone in reversing overdoses and saving lives, PWUDs, especially those experiencing limited opportunity structures related to poverty and homelessness, experience multiple structural barriers to obtaining and retaining naloxone.(10, 11) For instance, PEUH repeatedly lose access to their naloxone supply due to involuntary displacement practices (e.g. encampment sweeps).(11) A recent study found that being unhoused was negatively associated with currently owning naloxone compared to being housed.(11) To address this disparity, public health researchers have recommended the development and implementation of naloxone scale-up interventions among PEH.(11, 12)

In response to these national and state trends in opioid-related overdoses among PEUH, a local homeless collaborative, the Bakersfield Kern Regional Homeless Collaborative (BKHRC), implemented a novel naloxone distribution intervention during the 2024 PIT Count to expand access to naloxone among PEUH in Kern County, California. The PIT Count is an annual count of sheltered and unsheltered homelessness on a designated single night during the last ten days of January conducted by 381 Continuum of Care (CoC) programs throughout the United States.(6, 13) The intervention was comprised of two components – optional attendance of an opioid overdose education and naloxone distribution (OEND) training for PIT Count volunteers and optional distribution of naloxone by volunteers to PEUH during the PIT Count. Previous research has shown OEND programs to be safe, cost-effective, and effective in reducing opioid overdose mortality.(14, 15, 16, 17, 18)

The primary objective of this pilot study was to assess the retrospective acceptability of OEND training and the subsequent distribution of naloxone during the annual PIT Count amongst volunteers using the Theoretical Framework of Acceptability (TFA) developed by Sekhon and colleagues.(19) The TFA utilizes seven component constructs to assess the prospective, concurrent, or retrospective acceptability of healthcare interventions, including affective attitude, burden, ethicality, intervention coherence, opportunity costs, perceived effectiveness, and self-efficacy (see Fig. 1 for definitions and descriptions).(19) Previous research has established that assessing the acceptability of an intervention prior to effectiveness studies of the intervention is critical, as acceptable interventions possess a greater likelihood of being implemented.(19, 20) Therefore, the initial step in scaling this intervention was to determine the PIT Count volunteers’ perceptions about of the intervention (e.g. acceptability) to later inform formal ongoing local adoption of the intervention as well as future research on the effectiveness of the intervention and dissemination to other CoCs, which organize and implement PIT Counts nationwide.

An electronic quantitative survey informed by the TFA (19) was conducted, with the aim of evaluating the acceptability of the novel PIT Count naloxone training and distribution initiative among PIT Count volunteers. Participants were recruited through a convenience sample using the BKHRC listserv between February and March 2024. Participants were eligible if they had participated as a volunteer in the 2024 PIT Count in Kern County and aged 18 years and older. Participants who met the inclusion criteria and completed the survey were eligible for a raffle drawing for one of four $50 gift cards.

The survey included written informed consent, inclusion/exclusion screen, and a request for an email address if the participant was interested in entering the raffle drawing. In addition to sociodemographic and intervention participation questions, specific questions related to respondents’ history with witnessing opioid related overdoses and use of bystander responses to overdose emergencies were included. The survey also contained questions designed to obtain the participants’ level of agreement with components of acceptability for both aspects of the intervention - OEND training prior to the PIT Count and naloxone distribution during the PIT Count. The survey also sought to obtain feedback about the intervention through items such as, “I would be willing to distribute Narcan during the next Kern County PIT Count (2025)” accompanied by a Likert scale for agreement and “reasons for not distributing naloxone during the PIT Count.”

Participants completed the electronic survey independently through Qualtrics. After completing the raffle drawing using the randomizer, the dataset was de-identified and provided to the research team. Study results were shared with the BKHRC and PIT Count Committee.

Descriptive analyses were conducted in IBM SPSS Statistics (Version 29) to describe the participants’ sociodemographic characteristics as well as the means, standard deviations, and frequencies of the sample’s history of witnessing and responding to opioid overdose emergencies, participation in the PIT Count OEND training and naloxone distribution efforts, the acceptability items for the OEND training and naloxone distribution efforts, and willingness to distribute naloxone at future PIT Counts.

The study protocol was reviewed and approved by the California State University, Bakersfield Human Subjects Institutional Review Board (IRB# 25–55).

One hundred eleven respondents initiated the survey; however, only ninety-seven met the eligibility screening requirements. Three (3.1%) of these participants were excluded from the analyses due to discontinued surveys after completing the screening requirements for a final analytic sample of 94. Sociodemographics for the entire sample, the naloxone training participants, and the naloxone distribution participants are reported in Tables 1–3.

Over one-quarter of respondents (n = 26) stated that they previously witnessed an opioid related overdose emergency with most of these respondents (88.5%) indicating that they engaged in a bystander intervention to support the overdose victims. Fifteen of these respondents reported that they employed multiple bystander interventions. The most popular bystander interventions included administering naloxone (n = 15), calling 911 (n = 14), and physical stimulation (n = 6). For the 19 respondents who reported the number of opioid overdose emergencies they witnessed, they witnessed an average of 2.21 overdose emergencies (range 1 to 6; STD 1.619). Of the 7 respondents who indicated the number of times they previously administered naloxone to an overdose victim, they administered naloxone 1.29 times on average (range 0 to 3; mean 1.29) (see Table 1).

Table 1

Descriptive Statistics for All Respondents
	Mean/SD or percent (n)
Sociodemographics
Gender
Male	24.5% (n = 23)
Female	70.2% (n = 66)
Non-binary/Third gender	2.1% (n = 2)
Prefer not to say	1.1% (n = 1)
Missing	2.1% (n = 2)
Age
	range: 24–88 years; mean: 39.69; STD 12.729
Race/Ethnicity
White	36.2% (n = 34)
Black	2.1% (n = 2)
Hispanic/Latino(a)/Latinx	41.5% (n = 39)
Asian	2.1% (n = 2)
Hawaiian/Other Pacific Islander	1.1% (n = 1)
American Indian/Alaska Native	4.3% (n = 4)
2 or More Racial/Ethnic Identities	8.5% (n = 8)
Other	2.1% (n = 2)
Missing	2.1% (n = 2)
Occupational Setting
Behavioral health	17.0% (n = 16)
Social services	24.5% (n = 23)
Healthcare	10.6% (n = 10)
Government agency	13.8% (n = 13)
Child welfare	2.1% (n = 2)
Older adult services	1.1% (n = 1)
Faith-based organization	5.3% (n = 5)
Other	23.4% (n = 22)
Missing	2.1% (n = 2)
Years of Participation in the PIT Count
1 Year	55.3% (n = 52)
2 Years	20.2% (n = 19)
3 Years	13.8% (n = 13)
4 + Years	8.5% (n = 8)
Missing	2.1 (n = 2)
Overdose Management History
Witnessed an overdose
Yes	66.0% (n = 62)
No	27.7% (n = 26)
Prefer not to say	2.1% (n = 2)
Missing	4.3% (n = 4)
Number of times witnessed an OD
	range 1 to 6; mean 2.21; STD 1.619
Overdose response strategies
Gave them naloxone	19
Called 911	20
Physical stimulation	6
Chest compressions	5
Mouth-to-mouth resuscitation/CPR	3
Cold water or ice	4
Did something else (other)	2
Number of times administered naloxone in the past year
	range from 0 to 3; mean 1.29; STD .951
Participation in the intervention
Participated in the PIT Count OEND Training
Yes	71.3% (n = 67)
No	25.5% (n = 24)
Missing	3.2% (n = 3)
Distributed naloxone during the PIT Count
Yes	64.8% (n = 61)
No	28.7% (n = 27)
Missing	6.4% (n = 6)
Number of naloxone kits distributed during the PIT Count
	range 1–40; mean 8.59; STD 8.456
Willingness to distribute naloxone at future PIT Counts
Strongly agree	69.1% (n = 65)
Somewhat agree	13.8% (n = 13)
Neither agree nor disagree	5.3% (n = 5)
Somewhat disagree	1.1% (n = 1)
Strongly disagree	6.4% (n = 6)

Over two-thirds of respondents (n = 67) reported that they participated in the OEND training opportunity. Sixty-five respondents reported the type of training they attended – 22 attended the in-person training and 43 viewed the asynchronous video training (see Table 2).

Respondents who participated in the OEND training indicated their level of agreement with each statement corresponding to five of the components of the TFA.(19) For affective attitude, 40 respondents reported that they liked the training “a great deal,” and 15 responded they liked the training “somewhat” (average score of 1.57 on a 5-point scale). In terms of burden, 26 respondents stated that it took no effort to participate, and 29 indicated that it took “a little effort” (average score of 1.89 on a 5-point scale). Similarly, respondents also reported a low opportunity cost associated with participating in the training with most (n = 47; average score of 4.40 on a reverse 5-point scale) strongly disagreeing that “Participating in the Narcan Training interfered with my other priorities.” Additionally, respondents reported a high level of perceived effectiveness of the naloxone training with 39 strongly agreeing and 20 somewhat agreeing with the statement (average score of 1.58 on a 5-point scale), “The Narcan Training has improved my knowledge of signs of an opioid overdose and how to administer Narcan during an overdose emergency.” However, respondents reported a respectively lower level of agreement related to self-efficacy with only 17 stating that they were “very confident" and 34 “confident” (average score of 2.23 on a 5-point scale) with “identifying an opioid overdose emergency and administering naloxone.” Overall, the OEND training was regarded as highly acceptable among the respondents with all reporting it was completely acceptable (n = 41), acceptable (n = 19), or no opinion (n = 5) (average score of 1.45 on a 5-point scale) (see Table 2).

Table 2

Descriptive Statistics for Participants who Attended OEND Training
	Mean/SD or percent (n)
Sociodemographics
Gender
Male	25.4% (n = 17)
Female	71.6% (n = 48)
Non-binary/Third gender	1.5% (n = 1)
Prefer not to say	1.5% (n = 1)
Age
	Range 24 to 77; mean 38.20; STD 11.25
Race/Ethnicity
White	35.8% (n = 24)
Black	1.5% (n = 1)
Hispanic/Latino(a)/Latinx	46.3% (n = 31)
Asian	3.0% (n = 2)
Hawaiian/Other Pacific Islander	0.0% (n = 0)
American Indian/Alaska Native	3.0% (n = 2)
2 or More Racial/Ethnic Identities	7.5% (n = 5)
Other	3.0% (n = 2)
Occupational Setting
Behavioral health	20.9% (n = 14)
Social services	22.4% (n = 15)
Healthcare	11.9% (n = 8)
Government agency	14.9% (n = 10)
Child welfare	1.5% (n = 1)
Older adult services	0.0% (n = 0)
Faith-based organization	4.5% (n = 3)
Other	23.9% (n = 16)
Years of Participation in the PIT Count
1 Year	58.2% (n = 39)
2 Years	22.4% (n = 15)
3 Years	13.4% (n = 9)
4 + Years	6.0% (n = 4)
Mode of OEND Training
In-person	32.8% (n = 22)
Asynchronous video	64.2% (n = 43)
Missing	3.0% (n = 2)
Acceptability of the OEND Training
Did you like or dislike the Narcan training? (Affective Attitude)
Like a great deal	59.7 (n = 40)
Like somewhat	22.4% (n = 15)
Neither like nor dislike	13.4% (n = 9)
Dislike somewhat	0.0% (n = 0)
Dislike a great deal	1.5% (n = 1)
How much effort did to take to participate in the Narcan training? (Burden)
None at all	38.8% (n = 26)
A little effort	43.3% (n = 29)
No opinion	7.5% (n = 5)
A lot of effort	1.5% (n = 1)
A great deal of effort	6.0% (n = 4)
The Narcan Training has improved my knowledge of signs of an opioid overdose and how to administer Narcan during an overdose emergency. (Perceived Effectiveness)
Strongly agree	58.2% (n = 39)
Somewhat agree	29.9% (n = 20)
Neither agree nor disagree	3.0% (n = 2)
Somewhat disagree	3.0% (n = 2)
Strongly disagree	3.0% (n = 2)
How confident do you feel about identifying an opioid overdose emergency and administering Narcan? (Self-Efficacy)
Very confident	25.4% (n = 17)
Confident	50.7% (n = 34)
No opinion	3.0% (n = 2)
Unconfident	9.0% (n = 6)
Very unconfident	9.0% (n = 6)
Participating in the Narcan Training interfered with my other priorities. (Opportunity Costs)
Strongly agree	3.0% (n = 2)
Somewhat agree	4.5% (n = 3)
Neither agree nor disagree	13.4% (n = 9)
Somewhat disagree	6.0% (n = 4)
Strongly disagree	70.1% (n = 47)
How acceptable was the Narcan training to you? (General Acceptability)
Completely acceptable	61.2% (n = 41)
Acceptable	28.4% (n = 19)
No opinion	7.5% (n = 5)
Unacceptable	0.0% (n = 0)
Completely unacceptable	0.0% (n = 0)

Almost two-thirds of the respondents (n = 61) reported that they distributed naloxone during the 2024 PIT Count. Of these respondents, 58 shared the number of naloxone kits they distributed during the 2024 PIT Count with an average of 8.59 kits distributed (range 1 to 40; STD 8.456) (see Table 3).

Respondents who distributed naloxone during the unsheltered PIT Count reported their level of agreement related to all seven components of the TFA.(19) To assess affective attitude toward naloxone distribution during the PIT Count, respondents reported varying levels of comfort with 34 reporting they were “extremely comfortable,” 6 “somewhat comfortable,” 8 neutral, 7 “somewhat uncomfortable,” and 12 “extremely uncomfortable” (average of 2.05 on a 5-point scale). However, the respondents reported a high level of self-efficacy for the intervention with 51 respondents rating themselves as “confident” to “very confident” and only 3 reporting they were “unconfident” or “very unconfident” (average of 1.73 on a 5-point scale). In terms of burden, most of these respondents (n = 49) reported that distributing naloxone took “little” to “no effort at all” (average of 1.80 on a 5-point scale). Moreover, most respondents (n = 50) reported a low opportunity cost for participating in the intervention and disagreed or strongly disagreed with the statement, “Distributing Narcan during the PIT Count got in the way of my other priorities for the PIT Count” (average of 4.52 on a reverse 5-point scale). For ethicality, many respondents who distributed naloxone rated the intervention as “fair” (n = 17) or “very fair” (n = 34) (average 1.68 on a 5-point scale). Respondents also rated the intervention highly for perceived effectiveness with most strongly to somewhat agreeing that it improved access to naloxone among PEUH (n = 45; average of 1.80 on a 5-point scale). Similarly, the respondents also reported a high level of intervention coherence with 37 strongly agreeing and 15 somewhat agreeing with the statement, “It is clear to me how distributing Narcan during the PIT Count will help improve persons access to Narcan among persons experiencing homelessness.” Importantly, over three-quarters of these respondents (n = 46) reported that the intervention generally was either acceptable or completely acceptable to them (average of 1.77 on a 5-point scale) (see Table 3).

Table 3

Descriptive Statistics for Participants who Distributed Naloxone during the PIT Count
	Mean/SD or percent (n)
Sociodemographics
Gender
Male	24.6% (n = 15)
Female	70.5% (n = 43)
Non-binary/Third gender	1.6% (n = 1)
Prefer not to say	1.6% (n = 1)
Missing	1.6% (n = 1)
Age
	Range 24 to 74; mean 39.35; STD 11.01
Race/Ethnicity
White	41.0% (n = 25)
Black	1.6% (n = 1)
Hispanic/Latino(a)/Latinx	39.3% (n = 24)
Asian	3.3% (n = 2)
Hawaiian/Other Pacific Islander	1.6% (n = 1)
American Indian/Alaska Native	3.3% (n = 2)
2 or More Racial/Ethnic Identities	4.9% (n = 3)
Other	3.3% (n = 2)
Missing	1.6% (n = 1)
Occupational Setting
Behavioral health	19.7% (n = 12)
Social services	18.0% (n = 11)
Healthcare	14.8% (n = 9)
Government agency	18.0% (n = 11)
Child welfare	1.6% (n = 1)
Older adult services	0.0% (n = 0)
Faith-based organization	6.6% (n = 4)
Other	19.7% (n = 12)
Missing	1.6% (n = 1)
Years of Participation in the PIT Count
1 Year	57.4% (n = 35)
2 Years	19.7% (n = 12)
3 Years	11.5% (n = 7)
4 + Years	9.8% (n = 6)
Missing	1.6% (n = 1)
Acceptability of Naloxone Distribution during PIT Count
How comfortable did you feel distributing Narcan during the PIT Count? (Affective Attitude)
Extremely comfortable	55.7% (n = 34)
Somewhat comfortable	9.8% (n = 6)
Neither comfortable nor uncomfortable	13.1% (n = 8)
Somewhat uncomfortable	11.5% (n = 7)
Extremely uncomfortable	8.2% (n = 5)
Missing	1.6% (n = 1)
How much effort did it take to distribute Narcan during the PIT Count? (Burden)
None at all	44.3% (n = 27)
A little effort	39.3% (n = 24)
No opinion	3.3% (n = 2)
A lot of effort	8.2% (n = 5)
A great deal of effort	1.6% (n = 1)
Missing	3.3% (n = 2)
How fair do you believe it is to distribute Narcan during the PIT Count to unsheltered persons experiencing homelessness? (Ethicality)
Very fair	55.7% (n = 34)
Fair	27.9% (n = 17)
No opinion	9.8% (n = 6)
Unfair	0.0% (n = 0)
Very unfair	4.9% (n = 3)
Missing	1.6% (n = 1)
Distributing Narcan during the PIT Count has improved access to Narcan among persons experiencing homelessness. (Perceived Effectiveness)
Strongly agree	52.5% (n = 32)
Somewhat agree	24.6% (n = 15)
Neither agree nor disagree	14.8% (n = 9)
Somewhat disagree	1.6% (n = 1)
Strongly disagree	4.9% (n = 3)
Missing	1.6% (n = 1)
It is clear to me how distributing Narcan during the PIT Count will help improve persons access to Narcan among persons experiencing homelessness. (Intervention Coherence)
Strongly agree	60.7% (n = 37)
Somewhat agree	24.6% (n = 15)
Neither agree nor disagree	9.8% (n = 6)
Somewhat disagree	1.6% (n = 1)
Strongly disagree	1.6% (n = 1)
Missing	1.6% (n = 1)
How confident do you feel about distributing Narcan during the PIT Count? (Self-Efficacy)
Very confident	49.2% (n = 30)
Confident	34.4% (n = 21)
No opinion	9.8% (n = 6)
Unconfident	1.6% (n = 1)
Very unconfident	3.3% (n = 2)
Missing	1.6% (n = 1)
Distributing Narcan during the PIT Count got in the way of my other priorities for the PIT Count. (Opportunity Cost)
Strongly agree	1.6% (n = 1)
Somewhat agree	1.6% (n = 1)
Neither agree nor disagree	13.1% (n = 8)
Somewhat disagree	9.8% (n = 6)
Strongly disagree	72.1% (n = 44)
Missing	1.6% (n = 1)
How acceptable was distributing Narcan during the PIT Count to you? (General Acceptability)
Completely acceptable	52.5% (n = 32)
Acceptable	26.2% (n = 16)
No opinion	14.8% (n = 9)
Unacceptable	0.0% (n = 0)
Completely unacceptable	4.9% (n = 3)
Missing	1.6% (n = 1)
Reasons for Not Distributing Naloxone during the PIT Count
None of the PIT Count survey participants wanted Narcan.	12
I did not have time to distribute Narcan to PIT Count survey participants due to amount of surveys I needed to complete during the PIT Count	1
Other members of my team distributed Narcan, but I did not have an opportunity to distribute it.	8
I was not comfortable distributing Narcan to PIT Count survey participants.	2
I did not feel confident providing information about how to use Narcan to PIT Count survey participants.	1

Of the 33 respondents who did not distribute naloxone during the unsheltered PIT count, 24 reported the reason that they did not participate in this aspect of the intervention. Half of these respondents (n = 12) indicated that PIT Count survey participants they interacted with declined the naloxone kit. One third (n = 8) stated that while other members of their assigned PIT Count team distributed naloxone, they did not have an opportunity to distribute it. Two respondents reported that their affective attitude (comfort) dissuaded them from distributing naloxone during the PIT Count. One respondent attributed their lack of self-efficacy in providing information about how to use naloxone, and another related to opportunity cost and lack of time to distribute naloxone and complete the surveys during the PIT Count as reasons for abstaining from naloxone distribution (see Table 3).

Ninety respondents indicated their level of agreement with the statement, “I would be willing to distribute Narcan during the next Kern County PIT Count (2025).” Over 87% of these participants indicated that they somewhat agreed (n = 13) to strongly agreed (n = 66) with only 6 somewhat disagreeing (n = 1) to strongly disagreeing (n = 5) (average of 1.51 on a 5-point scale) (see Table 1).

Within open-ended responses about suggestions for improvement for the naloxone training and distribution efforts during the PIT Count, several themes emerged related to the OEND training, quantity of naloxone kits provided to the volunteer teams, the additional supplies needed for naloxone distribution during the PIT Count, and support around naloxone messaging and training with PEUH during the PIT Count. Regarding OEND training, respondents requested increased availability of in-person training sessions, mandatory/universal OEND training for volunteers, training opportunities throughout the year, and refresher demonstrations for administering naloxone the morning of the PIT Count at the headquarters. Several respondents indicated that teams should be allocated a greater quantity of naloxone at the start of the PIT Count, as they quickly ran out and experienced delays in obtaining more from the central headquarters. Some respondents also stated that it would be more expedient to provide each volunteer with a tote bag/backpack of naloxone rather than providing the box of 12 to the team. Another respondent suggested that the naloxone be included as a standard item in each of the hygiene bags distributed to PIT Count survey participants, eliminating the opt-in approach for volunteers and survey participants. Other supplies requested by respondents included latex gloves and CPR shields to enhance their ability to respond to an overdose emergency during the PIT Count. Finally, the respondents requested support with messaging for PEUH about the value of naloxone to save the life of others rather than an indication about whether one is actively engaged in substance use as well as field demonstrations for PEUH on how to administer naloxone.

The current study aimed to determine the acceptability of a novel approach to expanding access to naloxone among PEUH by providing an optional OEND training to PIT Count volunteers and opportunity for distribution of naloxone kits to PEUH during an annual PIT Count. Additionally, this study is the first to evaluate the acceptability of OEND training and naloxone distribution during an annual PIT Count. The results of this study strengthen the emerging support for the acceptability of implementing OEND training and naloxone distribution efforts during annual PIT Counts to increase access to naloxone among PEUH and reduce preventable opioid related overdose fatalities among this population with multiple vulnerabilities.

The OEND training and naloxone distribution components of the intervention were both acceptable, as demonstrated by strong ratings across the respective acceptability response items and a high level of agreement with the statement, “I would be willing to distribute Narcan during the next Kern County PIT Count (2025).” Using the TFA to guide a retrospective assessment of the acceptability of the PIT Count OEND training and naloxone distribution initiative highlighted potential factors contributing to acceptability of this low-cost, low-barrier novel intervention among PIT Count volunteers. For the OEND training, most participants perceived there to be limited opportunity costs and burden, as this brief training was embedded within the mandatory PIT Count training provided to volunteers. This result aligns with findings from Brandt et al. (21) regarding the impact of the timeframe on participants’ acceptability of OEND and supported as an evidence-based practice from studies reporting that brief trainings have been adequate to impart basic knowledge of overdose management (17, 22). While most participants reported that they liked the training (affective attitude) and that it increased their ability to recognize the signs of an opioid overdose emergency and administer naloxone (perceived effectiveness), they rated their self-efficacy the lowest out of all acceptability response items. Previous research has shown that OEND training enhances participants’ knowledge of overdose management (22, 23, 24, 25, 26, 27, 28, 29, 30), which aligns with the present study’s findings related to perceived effectiveness. However, these studies also indicate that OEND training improves participants’ confidence (self-efficacy) in overdose management (22, 23, 24, 25, 26, 27, 28, 29, 30). While our participants provided retrospective scoring of the self-efficacy item post-intervention, this study did not include pre-test and post-test measures to assess improvements in participants’ knowledge and confidence in overdose management. Overall, this component of the intervention was also perceived as highly acceptable among respondents. These findings about the acceptability of the OEND training coincide with a previous study of OEND trainings, in which trainees reported that the intervention was highly acceptable (21).

For the naloxone distribution during the PIT Count, the participants also reported limited to no opportunity costs and burden associated. Since PIT Count volunteers already devote time to engaging with PEUH and distributing supplies during the annual PIT Count, offering naloxone to PEUH during their usual duties was not perceived to increase the amount of effort or interfere with their priorities during the PIT Count. Most respondents also perceived naloxone distribution among PEUH to be fair, coherent, and effective in increasing access to naloxone among PEUH. While self-efficacy for distributing naloxone was high, affective attitude (comfort) was lower for distributing naloxone to PEUH during the PIT Count. Overall, participants in this component of the intervention perceived naloxone distribution to PEUH during the PIT Count to be highly acceptable. To our knowledge, this is the first study to explore the acceptability of naloxone distribution strategies among community members engaged in outreach efforts with PEUH.

As respondents noted in the open-ended response field, additional supplies were needed to enhance the comfort of volunteers in distributing naloxone and responding to opioid overdose emergencies during the PIT Count. Furthermore, respondents also requested more training for the messaging around naloxone and demonstrating naloxone administration to PEUH during the PIT Count. Incorporating these elements into future iterations of the intervention may address concerns related to their self-efficacy with overdose management and affective attitude (comfort) with naloxone distribution during the PIT Count.

Despite the above discussed positive outcomes of this study and its novel contributions to current OEND interventions among PEUH, it was not without limitations. First, as a pilot study, no definitive conclusions about efficacy could be made. The focus of the current study was to assess the acceptability of this intervention among PIT Count volunteers and to provide strong preliminary data for an effectiveness study.

Second, one of the central goals for this novel naloxone distribution initiative was to increase access to naloxone among PEUH. While the study tracked the number of naloxone kits distributed (n = 591), it did not record the number of PEUH who obtained naloxone. Additionally, this study was unable to assess the acceptability of this intervention among PEUH, creating gaps in our understanding of the targeted recipients’ perceptions and satisfaction with the intervention.

Third, our sample was small. While 94 respondents met the eligibility criteria to participate in the survey, about two-thirds of respondents reported that they completed the OEND training and distributed naloxone during the PIT Count, respectively. Another limitation involved the use of a convenience sample approach. Even though our sample was diverse, it was unknown whether it is representative of the larger PIT Count volunteer population across the country.

A fifth limitation was that the high rating of acceptability for the OEND training and naloxone distribution during the PIT Count might have been the result of selection bias. Due to the design of our opt-in nature of the OEND training and naloxone distribution during the PIT Count, only participants who completed the OEND training and participated in naloxone distribution during the PIT Count were able to rate the acceptability of these elements of the intervention. The acceptability of OEND training and naloxone distribution during the PIT Count might have been lower among those PIT Count volunteers who did not self-select to participate in the intervention.

Finally, our results were specific to the BKRHC CoC and PIT Count volunteers in Kern County. Barriers to providing OEND training and naloxone kits may vary depending on the resources of the local CoC and number of volunteers and PEUH. For instance, smaller rural areas may lack access to competent OEND trainers and may not have an adequate supply of naloxone to distribute. Conversely, municipalities with a high volume of PEUH, like Los Angeles County, may experience difficulties scaling this intervention to provide OEND training to the numerous volunteers and amassing a large quantity of naloxone kits for their volunteers to distribute.

Even considering these limitations, this study was the first to explore the acceptability of a novel low-cost, low-barrier naloxone distribution intervention targeting PEUH that could support future inquiry to the efficacy of this intervention. Overall, by exploring the effectiveness of this approach through continued research, naloxone engagement among PEUH could improve, resulting in a decrease of preventable overdose fatalities amongst this population.

There is an emphasis on developing novel approaches to improving naloxone cascades among PEUH to reduce opioid overdose fatalities among this population, especially Black and Latine persons. Examining the acceptability of these interventions is imperative to increase the widespread adoption of these approaches. Our findings may guide future dissemination and implementation of OEND training and naloxone distribution efforts during PIT Counts across CoCs in the United States, enhancing access to life-saving naloxone among unhoused persons who are the most likely to experience or witness a preventable opioid-related overdose death. Additional research on the effectiveness of this intervention may be required to evaluate the delivery and outcomes of the intervention.

PIT Point-in-Time

CoC Continuum of Care

PEH Persons experiencing homelessness

PEUH Persons experiencing unsheltered homelessness

PWUD People who use drugs

OEND Opioid overdose education and naloxone distribution

TFA Theoretical Framework of Acceptability

BKRHC Bakersfield Kern Regional Homeless Collaborative

Ethical approval and consent to participate

This study was approved by California State University, Bakersfield’s Human Subjects Institutional Review Board, #25-55.

Consent for publication
Not applicable.

Availability of data and materials

The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.

Competing interests

The authors declare that they have no competing interests.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

Authors’ contributions

AH designed the study, analyzed and interpreted the data, and wrote the first draft of the manuscript. KR contributed to the original design of the study and provided support in the data analysis process. All authors contributed to the revision of the manuscript and read and approved the final manuscript.

Acknowledgments

The authors would like to acknowledge the support and cooperation of the Bakersfield Kern Regional Homeless Collaborative (BKRHC), Kern Behavioral Health and Recovery Services (KernBHRS) Prevention Team, and California State University, Bakersfield (CSUB) – Department of Social Work. A special thanks to Rick Ramos, Mary Scott, Manuel Vieyra, Destiny Reveles, Jamie Bowman, Maribel Bautista-Vega, and the 2024 PIT Count volunteers. The authors also recognize the lives lost to preventable opioid overdose fatalities in their community.

Authors’ information

AH is an Assistant Professor in the Department of Social Work at California State University, Bakersfield. She is a Licensed Clinical Social Worker (LCSW) and has been practicing since 2012. AH is also the CEO and Founder of HOPE in the Valley, a syringe service program (SSP) in Kern County, and provides field supervision and training for Master of Social Work students to increase their competence and confidence with evidence-based harm reduction practices to empower PWUDs and people engaged in sex work to save their own lives. KR is an Associate Clinical Social Worker (ASW) and a volunteer with HOPE in the Valley. AH and KR are members of the BKHRC and Drug Free Kern.

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A novel naloxone distribution intervention among persons experiencing unsheltered homelessness: Acceptability of naloxone training and distribution during an annual Point-in-Time Count

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