Review of: Colledge-Frisby S et al, JAMA Netw Open 2023;6(8):e2327319

Study Type: Prospective cohort

Naloxone, an opioid antagonist, can rapidly reverse the effects of opioid overdoses, and its widespread distribution has saved lives. Take-home naloxone (THN) programs were developed to provide overdose-response education and to supply naloxone to anyone likely to witness an overdose. Overall, THN programs are effective at reducing overdose deaths; however, there is a question of whether naloxone’s availability might lead some individuals to take more chances with drugs since there is a rescue remedy close at hand—a phenomenon called risk compensation (McDonald R and Strang J, Addiction 2016;111(7):1177–1187).

To answer this question, researchers assessed risk behaviors among 1,328 people who inject drugs (opioids and/or methamphetamine) before and after THN training. Trainings were provided by local substance use and harm reduction organizations and consisted of overdose prevention and response instruction plus supplied intramuscular or intranasal naloxone. The primary outcome measure was injection frequency along with other secondary measures associated with increased overdose risk, including opioid injecting, benzodiazepine use, and using drugs alone.

Of the 1,328 participants, researchers had sufficient data on 189 of them to include in the final analysis. They used multilevel modeling to control for confounding factors and expressed findings as incidence rate ratios (IRR) with 95% confidence intervals (CI). There were no significant changes in any of the measured risk behaviors after individuals underwent THN training. Specifically, there was a small nonsignificant decrease in overall injection frequency (IRR 0.91; 95% CI 0.69–1.20; p = 0.51). In terms of secondary outcomes, researchers found no statistically significant changes in the frequency of opioid injecting (IRR 0.95; 95% CI 0.74–1.23; p = 0.71), benzodiazepine use (IRR 0.96; 95% CI 0.69–1.33; p = 0.80), or using drugs alone (IRR 1.04; 95% CI 0.86–1.26; p = 0.67). 

Carlat Take
The findings of the current study align with emerging data that THN programs do not promote riskier drug use behaviors. The notable dropout rate warrants caution when interpreting these results, but the consistency with prior research is reassuring and underscores the importance of continuing naloxone distribution.