BACKGROUND: Opioid-related deaths are increasing globally, and synthetic opioids intensify overdose risk. Naloxone can prevent fatalities, although too much can precipitate withdrawal and other negative reactions for the person overdosing. There is an increasing range of naloxone products, some providing very high doses, and this has generated different opinions on how much naloxone is necessary to save a life without causing harm. This paper explores how non-medical first-responders administer naloxone at opioid overdoses in the UK.

METHODS: Qualitative telephone interviews were conducted (2021-2023) with people who used services (n = 21, of whom 20 used opioids) and staff working with people who used opioids (n = 7). Participants had all been supplied with naloxone (predominantly injectable Prenoxad) and routine naloxone training as part of a separate cohort study. All had witnessed an overdose in the previous six months. Interviews were semi-structured, audio-recorded and transcribed. Data were coded and analyzed via Iterative Categorization.

RESULTS: Overdoses occurred within a framework of uncertainty. Participants were often unsure of the types and quantities of drugs consumed and did not always know if, or how much, naloxone had been administered. No deaths and few cases of withdrawal were reported, but other negative effects (including disorientation and anger) were common. On witnessing a potential overdose, participants made numerous decisions quickly. These included confirming the overdose and deciding whether naloxone was needed, who would administer it, when doses should be given, and when to stop dosing. These decisions were influenced by contextual factors, including the availability of a naloxone device, panic, prior knowledge of the person who overdosed, the helpfulness (or otherwise) of others present, and any training previously received.

CONCLUSIONS: Naloxone dosing is complex and often reactive rather than purely scientific. Non-medical responders are competent at saving lives using naloxone, but do not always achieve resuscitation without negative effects. Findings highlight the value of offering optional advanced training and regular refresher training. This should focus on locally used naloxone products and dosing decision-making, plus experiential training that might enable people to anticipate how they would feel in a time-pressured overdose-related situation and so respond more calmly.