Behavioral economic strategies to increase naloxone acquisition and carrying

Background: The opioid overdose crisis claimed over 80,000 American lives in 2019, with opioids implicated in the majority of these deaths. The COVID-19 pandemic has exacerbated the crisis, with challenges arising from the increased use of fentanyl, synthetic opioids, and combined opioid-stimulant substances. Urgent strategies are required to mitigate drug-related harms in the context of an unsafe drug supply. Objective: This paper presents the findings of two consecutive randomized controlled trials conducted in Philadelphia, aiming to assess the effectiveness of behavioral economic interventions in promoting naloxone acquisition and carrying among adults. Methods: The trials focused on increasing naloxone acquisition (Study A) and promoting naloxone carrying (Study B) among participants who completed community-based overdose recognition and reversal training. Participants were randomized into three arms: those receiving text message nudges, those signing commitment contracts, and a control group receiving only in-person overdose reversal training. Data collection utilized a web-based platform, and participants were compensated upon study completion. Results: In Study A, participants were encouraged to acquire naloxone, and the primary endpoint was naloxone acquisition within four weeks post-training. Results showed that around one in five participants acquired naloxone, regardless of the intervention arm, indicating limited effectiveness of behavioral strategies in promoting naloxone acquisition. In Study B, where all participants received naloxone by default, the primary endpoint was the consistency of naloxone carrying. Participants had naloxone on hand at approximately half of the eight unannounced check-ins, with no significant differences between intervention groups and the control group. Conclusion: Naloxone distribution by default emerges as a promising strategy to increase naloxone possession and save lives amidst the opioid overdose crisis. Addressing structural barriers, including cost and pharmacy availability, is essential. Additionally, interventions should consider leveraging motivations such as altruism and regret aversion to encourage naloxone carrying. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial NCT06064981 ### Funding Statement This study was funded by the Penn Roybal Center for Health Incentives and Behavioral Economics. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: University of Pennsylvania Institutional Review Board I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes All data produced in the present study are available upon reasonable request to the authors