Perceived Stigma Toward Naloxone Among Naloxone Training Attendees: Implications for Overdose Response

Background: Overdose education and naloxone distribution programs (i.e., naloxone trainings) are key strategies to reduce overdose fatalities. The goal is to distribute overdose reversal medication to people who may encounter an opioid overdose and prepare them to respond effectively. However, stigma is a documented barrier to successful program implementation, affecting training availability and participation. Because stigma has been shown to affect self-efficacy and intellectual performance, stigma may also diminish the efficacy of training among attendees. This study examines the relationship among perceived stigma toward naloxone, opioid overdose knowledge, and attitudes toward opioid overdose response among naloxone training attendees, and whether stigma's effect differs for attendees with intersecting stigma identities.

Methods: Adults who attended a naloxone training in Michigan (N=451) self-administered a web-based survey (February 2021 – March 2022). Surveys assessed socio-demographics (age, gender, race/ethnicity), substance use history (past overdose, injection drug use, or treatment), motivation for attending the training (friend, family member, or service provider), recency of training (past month), and perceived stigma toward naloxone (Bozinoff et al., 2018). Focal training outcomes were knowledge of opioid overdose management (Williams et al., 2013) and attitudes toward opioid overdose response (Williams et al., 2013). A moderated mediation model was used to assess the relationship among perceived stigma toward naloxone, knowledge of opioid overdose management, and attitudes toward overdose response, and the moderating effects of substance use history and racial-ethnic identity.

Results: In the moderated mediation model, after controlling for age, gender, motivation for training, and recency of training, greater perceived stigma toward naloxone (B=-.275, p=.045) and Black race (B=-6.093, p=.001) were associated with lower levels of knowledge. Greater knowledge was associated with more positive attitudes (B=.159, p<.001). Greater stigma was associated with less positive attitudes (B=-.570, p<.001). The indirect effect of stigma on attitudes through knowledge was significant for white participants only (bootstrapped CI -.088 to -.005). For white participants, greater stigma was associated with lower levels of knowledge (B=-.275, p=.045). No significant relationship between stigma and knowledge was observed among Black participants or participants of another race or ethnicity.

Conclusions and Implications: Regardless of racial-ethnic identity, greater perceived stigma toward naloxone was associated with less positive attitudes toward overdose response. However, the effect of perceived stigma on knowledge of overdose management varied by race. For white participants, greater stigma was associated with lower levels of knowledge, adding to a large body of research associating greater perceived stigma with poor health outcomes. For Black participants, however, no significant relationship between stigma and knowledge was observed. Given the legacy of racism in drug laws and policing, Black individuals who perceive greater stigma may be hypervigilant for potential harm related to carrying naloxone, which may manifest in greater knowledge acquisition surrounding opioid overdose response. Thus, while health communication campaigns to reduce stigma toward naloxone may improve training outcomes among white individuals, structural interventions may be necessary to address stigma among Black individuals. Culturally responsive naloxone distribution initiatives are urgently needed to reduce the growing racial disproportionality in overdose fatalities.