The opioid epidemic fits the “wicked problem” framework: it is high-stakes, dynamic, with definitions and solutions reflecting divergent values, and where well-meaning interventions may deepen challenges. With the 2017 loosening of federal guidelines regulating dispensing, naloxone distribution has become a key strategy for reducing fatalities. To evaluate efforts, states have focused on outputs like doses dispensed and outcomes like reported reversals and reductions in fatal opioid overdose rates. Despite this, fatal overdose rates have remained high. While available evidence implicates drug supply shifts from heroin to fentanyl and mental health impacts of the COVID-19 pandemic, this has created a challenge for harm reduction efforts. Using interview data collected as part of evaluating of a state-wide naloxone distribution initiative in New England, this paper describes how naloxone distributors understand their impact in the context of continued crises, pointing to “small wins” at the individual, organizational, and community levels as alternate measures of success.
Data come from semi-structured interviews with 47 individuals representing 32 organizations (17.2% of all naloxone distributors at the time of data collection). Interviews focused on strategies, successes, and challenges associated with naloxone distribution, perspectives on client risk and risk reduction, and experiences with training and evaluation. Organizations were selected to emphasize high-impact distribution and maximize the range of types represented. Sampled organizations account for most naloxone distributed statewide (58.1%, 31,145 doses) and most reported overdoses reversals (63.1%, 2,276) between September 2019 and July 2021. The sample includes behavioral health organizations (18.8%, 6), hospitals (18.8%, 6), public health entities (18.8%, 6), primary care clinics (15.6%, 5), outreach organizations (12.5%, 4), recovery support organizations (12.5%, 4), and correctional organizations (3.1%, 1). Interviews were audio recorded, transcribed verbatim, and analyzed thematically using Atlas.TI.
While distributors described receiving reversal reports as their most meaningful successes, these were relatively rare. Distributors pointed to examples at the individual, organizational, and community levels – conceptualized as small wins -- as alternative indicators. At the individual level, staff linked increases in client willingness to accept naloxone to effective relationship building and stigma reduction and clients declining naloxone due to existing access as evidence of community saturation. At the organizational level, distributors described cultural shifts as preconditions to and consequences of naloxone distribution. These included changes in language surrounding drug use, increased provider willingness to offer naloxone (versus providing it only on request), expansions from program-specific to universal distribution, and administrative willingness to publicize naloxone availability. At the community level, success meant connecting other community organizations to naloxone distribution efforts and a conviction that reversals were increasing, even if reports were not.
Conclusions & Implications
Small wins at the individual, organizational, and community levels provided distributors with evidence of their effectiveness in the context of the continued crises of the opioid epidemic and COVID-19 pandemic. Across levels, smalls wins were understood to reflect increased receptivity to harm reduction and decreased stigma towards people using drugs, both seen as essential to improving quality of life for high-risk individuals and ending the opioid epidemic.