











































MANUSCRIPT TYPE


EVIDENCE-TO-PRACTICE REVIEW  

 

33 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 2 – September 2021 

 
 

Community Opioid Overdose Prevention and Naloxone Distribution 
Programs: An Evidence-to-Practice Review  
Madison M. Hauge, SCAT, ATC; Kathryn C. Downs, SCAT, ATC; Zachary K. Winkelmann, PhD, SCAT, ATC 
University of South Carolina, Columbia, SC 

  

 
ABSTRACT 
According to the Centers for Disease Control and Prevention, 
100 people die of drug overdose in the United States every 
day. This frighteningly high mortality rate has created the 
need for community-based opioid overdose prevention 
programs (OOPPs).  Currently, there are more than 188 
community-run programs operating in the United States. 
These programs teach individuals how to distribute naloxone 
and respond properly to a drug overdose situation. This 
guiding systematic review depicts the current literature 
available on OOPPs and their effectiveness. The authors 
performed an article search to discover the most relevant and 
recent articles, which were graded using a quality assessment 
score. The search uncovered 19 articles deemed appropriate 
to investigate the effectiveness of OOPPs. Out of the 19 
articles, 14 of these articles were cohort studies with large 
sample sizes that did a baseline and follow-up survey at two 
different time periods. Almost 50% of participants in this 
review stated they personally experienced an opioid 
overdose in their life. Furthermore, there was 79.2% of 
participants (across the 8 studies that report this data) to 
witness a drug overdose. Nonmedical bystanders is defined 
as individuals who could properly reverse an opioid 
overdose when OOPP training was completed. Eleven studies 
detected a 100% survival rate post-naloxone administration 
with the remaining 8 studies not far behind with a survival 
rate range of 83-96%. The current evidence available 
suggests that OOPPs are successful in teaching their 
participants how to properly treat an opioid overdose with 
the administration of naloxone. 
 
Key Phrases 
Drug overdose/drug therapy, program evaluation, 
opioid-related disorders/drug therapy, 
naloxone/therapeutic use 
 
Correspondence 
Dr. Zachary Winkelmann, 1300 Wheat Street, Columbia, 
SC 29208. 
E-mail: winkelz@mailbox.sc.edu   
Twitter: @zachwinkelmann 
 
Full Citation 
Hauge MM, Downs KC, Winkelmann ZK. Community 
Opioid Overdose Prevention and Naloxone 
Distribution Programs: An Evidence-to-Practice 
Review. Clin Pract Athl Train. 2021;4(2): 33-39. 
https://doi.org/10.31622/2021/0004.2.5.    
 
Submitted: April 20, 2020 Accepted: November 16, 2021. 

 
 
 

ORIGINAL REFERENCE 
Clark AK, Wilder CM, Winstanley EL. A 
systematic review of community opioid 
overdose prevention and naloxone distribution 
programs. J Addict Med. 2014;8(3):153-163. 
 
SUMMARY 
 
CLINICAL PROBLEM AND QUESTION 
 

According to the World Health Organization, 

the three main symptoms for an opioid overdose 
(generally termed “opioid overdose triad”) are 
pinpoint pupils, unconsciousness, and respiratory 
depression.1 This fatal combination can ultimately 
result in death. In fact, 128 people die every day 
in the United States from opioid overdose.2,3 
According to the Centers for Disease Control and 
Prevention, opioid overdose is a rising issue in the 
United States with a 9.6% increase in the age-
adjusted rate in overdose deaths from 2016 to 
2017.4 In 2017, there were a total of 70,237 
drug overdose deaths.2  

To combat this public health emergency, opioid 
overdose prevention programs (OOPPs) were 
created to educate the public about how to 
recognize and manage an opioid overdose with 
treatment training using naloxone.2,5 Naloxone, 
which is commonly referred to by its brand name 
Narcan, is an opioid antagonist used to 
temporarily reverse a drug overdoses in an 
emergency situation. However, the drug is 
relatively new, and the opioid issue has continued 
to grow. In addition, OOPPs cover the risk factors 
of opioid overdose, as well as, the procedure of 
how to properly respond to an overdose with or 
without naloxone.1,2,4 Opioid overdose prevention 

mailto:winkelz@mailbox.sc.edu
https://doi.org/10.31622/2021/0004.2.5


Community Opioid Overdose Prevention and Naloxone Distribution Programs: An Evidence-to-Practice Review 
 

 

34 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 2 – September 2021 
 

programs are  essential since they  advocate for 
prevention efforts such as encouraging people 
(e.g., people at risk, the family members of 
people considered ‘at risk’, and healthcare 
providers) to learn how to manage a drug 
overdose.  

Opioid overdose prevention programs have been 
utilized in the United States for 24 years; though, 
there is very limited research on the programs’ 
impact and outcomes of the training.5-7 This 
evidence-to-practice review summarizes a 
systematic review to analyze the impact of 
OOPPs by evaluating if naloxone distribution 
reduces the instances of overdose among their 
participants.3  This review also compared the 
United States OOPPs effectiveness on increasing 
bystander knowledge on prevention, risk factors, 
and detection of and response to an opioid 
overdose.3 Lastly, it appraises how OOPPs 
participants respond to opioid overdose. Overall, 
this systematic review organizes the available 
current literature on opioid overdose to observe 
the general impact of OOPPs.  

SUMMARY OF LITERATURE 

The guiding systematic review searched 
databases including PubMed, MEDLINE, and 
PsychINFO, using the Boolean search query: 
(opioid OR opiate) AND overdose AND prevention. 
The search was limited to English language, which 
returned 360 different citations. The citations 
were sorted and included only original, peer-
reviewed articles examining community OOPPs 
that detected a training impact. This consisted of 
reports of overdose reversal rates, overdose 
fatalities, or any measure of overdose rate among 
program participants. Exclusion criteria included 
OOPPs that did not incorporate training on the use 
or distribute naloxone, data that was unable to 
separate into program-specific information, and 
program evaluations that focused more on health 
care personnel training. Thirty-eight articles were 
identified for full-text review; however, 19 

articles fit the exact inclusion conditions and were 
included in this review. The remaining 17 were 
excluded because these articles did not assess a 
community OOPP (11), did not report a training 
outcome (2),  did not have naloxone training (1), 
or were based on grouped or clumped data (2). 
A quality appraisal was completed on the articles 
involved in this systematic review. The quality 
score had a possible range of 4 – 8 and this set 
of studies used in the review had a mean of 6.1, 
median of 6.5, and a mode of 7. Although 
majority of these studies scored a 0 for 
randomization and low rates for follow-up, 
18/19 of these studies got a maximum score for 
sample size and outcomes. Overall, the studies 
were graded as fair based off descriptive 
quality.  

SUMMARY OF INTERVENTION  

The intervention investigated in the systematic 
review were OOPPs. The systematic review 
focused on the effectiveness of the OOPPs and 
their outcomes within the respective communities. 
The OOPP intervention ranged in duration from 
10-60 minutes. The laws for prescribing naloxone 
varied by state, as well as, the physician 
involvement with the OOPPs. Because of this, the 
qualifications of the personnel instructing the 
interventions differed between programs and in 
most studies the qualifications of the instructors 
were not specified.  Naloxone prescription is 
variable between states so involvement with 
physicians in OOPPs ranged from notification of 
program completion to meeting with a physician 
in order to receive a naloxone kit.8-10 

A majority of the programs include a curricula 
based on five components including: 1) 
recognizing overdose (78.9%), 2) preventing 
overdose (73%), 3) risk factors of overdose 
(63%), 4) appropriate response to overdose 
(84%) and, 5) administration of naloxone (100%) 
with some variation and deviations in the material 
provided. The response to overdose, such as 



Community Opioid Overdose Prevention and Naloxone Distribution Programs: An Evidence-to-Practice Review 
 

 

35 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 2 – September 2021 
 

rescue breathing, cardiopulmonary resuscitation 
(CPR), and the recovery position (Figure 1), were 
addressed in the majority of OOPPs. In addition, 
administering naloxone in a variety of ways and 
at varying levels of practice was a part of the 
curricula in each of the intervention programs. 
Fifteen of the articles provided training with 
needle-based administration, however, some 
programs provided training practice by injecting 
into an orange and while other programs used 
nasal naloxone. 11-13 

SUMMARY OF OUTCOMES 

The guiding systematic review analyzed outcomes 
of the OOPPs. The first analysis was for the 
outcomes associated with the reduction of fatal 
and nonfatal overdose rates for those who 
participated in an OOPP intervention. Naloxone 
was used successfully 1,949 times by those who 
attended OOPPs. This review identified heroin as 
the most frequently reported overdosed drug, 
despite the National Vital Statistics System 
indicating opioid analgesics as the highest drug 
used. The studies reported that the survival post-
naloxone administration rate ranged from 83%-
100% with 11 of the studies reporting a 100% 
survival rate. Two of the articles that reported 
lower survival rates attribute the findings to 
unknown overdose outcomes.10,14 In addition, two 
studies found that areas with higher OOPP 
enrollment demonstrated decreased opioid 
overdose mortality at a population level. 13,15 
With the majority of studies demonstrating 100% 
survival after administration of naloxone by those 
who attended OOPPs, we conclude that OOPPs 
have the ability to reduce fatal and nonfatal 
overdoses among participants.  

Next, the review analyzed the outcomes on the 
effectiveness of OOPPs to increase nonmedical 
bystander knowledge of prevention, risk factors 
and  recognition of opioid overdose and correct 
response. Just under half of the studies in the 
review reported pre- and post-training measures  

Figure 1. Demonstration of the recovery 
position in drug overdose management  

 
regarding the knowledge surrounding opioid 
overdose. The consensus among these studies is 
that those who participated in OOPPs had an 
increase in their knowledge of prevention, risk 
factors, and recognition of opioid overdose. 16-21  



Community Opioid Overdose Prevention and Naloxone Distribution Programs: An Evidence-to-Practice Review 
 

 

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Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 2 – September 2021 
 

In terms of response,  participants in OOPPs 
displayed a behavior change with an increase in 
appropriate responses like rescue breathing, 
administering naloxone, initiating recovery 
position, and performing a sternal rub.10,14, 17, 22 
However, in two studies there were reports of non-
recommended responses, such as using ice and 
cold water to revive patients.21, 22 These results 
display that the curriculum in studies that utilized 
pre- and post-training measures increased the 
knowledge of nonmedical bystanders.. This 
finding can be interpreted to show that 
nonmedical personnel have the ability to learn 
prevention, risk factors, and recognition of opioid 
overdose and therefore expand the population of 
those who can respond to opioid overdoses.  

 When considering the following outcomes 
associated with the reduction of fatal and 
nonfatal overdose rates for those who 
participated in an OOPP intervention and 
effectiveness of OOPPs to increase nonmedical 
bystander knowledge of prevention, risk factors 
and recognition of opioid overdose and correct 
response the literature shows that OOPPs may 
have the ability to create meaningful change 
within communities. OOPPs can reduce fatal and 
non-fatal overdoses.  The data suggests the 
ability for non-medical bystanders to learn about 
and properly respond to opioid overdoses. 
However, due to the nature of the studies and the 
way they have been conducted these, conclusions 
are limited due to the lack of randomization.  

FINDINGS AND CLINICAL IMPLICATIONS 

Due to the lack of randomization and systematic 
measures, it is difficult to create generalizable 
statements and conclusions of the effectiveness of 
the programs when the specific content is not 
documented. Although the evidence is not 
concrete, we can deduce that OOPPs have the 
potential to reduce opioid overdose morbidity 
and mortality. Clinically, to reproduce similar 
outcomes within our communities, athletic trainers 

and non-medical bystanders need to be educated 
on the five components of OOPPs: recognizing 
overdose, preventing overdose, risk factors for 
overdose, appropriate response to overdose, and 
administration of naloxone. We know that a 
100% survival rate can be achieved by attending 
OOPPs, and communities should focus on 
administration of naloxone as responses to 
overdose such as rescue breathing and CPR.  

Naloxone education and administration should be 
integrated into standards and practices of all first 
responder and healthcare providers. Standard 70 
in the 2020 Commission on Accreditation of 
Athletic Training Education (CAATE) standards 
describe that professional athletic training 
programs must teach how to evaluate and 
manage patients with acute conditions, including 
triaging conditions that are life threatening or 
otherwise emergent including drug overdose.23 
This includes the administration of naloxone. 
However, the goal should be to ensure that all ATs 
that completed formal education before this 
standard was implemented are also comfortable 
with the skill. This goal can also be achieved by 
incorporating elements of OOPPs into continuing 
education. By introducing OOPP education and 
training into athletic training continuing education 
we ensure athletic trainers can carry out the skills 
themselves as well as teach the skills in their 
communities.  By educating athletic trainers we can 
use them as a bridge to educate their respective 
communities. Athletic trainers serve unique roles 
that allow for them to be very involved within their 
surrounding communities, especially those in the 
secondary school settings. Communities should 
take advantage of this role that athletic trainers 
hold and use them as a liaison to instruct OOPPs 
in the communities they serve. Studies show that 
non-medical bystanders have been deemed 
efficient and successful in administering naloxone 
to those who have overdosed.16-21 This means that 
athletic trainers can teach anyone the OOPP 
curriculum and they have the potential to be 
successful in carrying out those skills. Athletic 



Community Opioid Overdose Prevention and Naloxone Distribution Programs: An Evidence-to-Practice Review 
 

 

37 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 2 – September 2021 
 

trainers can be extremely valuable by 
encouraging the high-risk populations that they 
know and interact with to attend OOPPs and help 
to cultivate better outcomes within the community.  

 Moving forward, the development of a 
standardized OOPP could be used to effectively 
educate groups across the country about opioid 
overdose and naloxone administration. Before a 
standardized OOPP is created, there is an 
opportunity for an OOPP assessment tool to be 
used to validate current programs. This tool would 
work towards deeming OOPPs efficient in 
education covering the five components; 
recognizing overdose, preventing overdose, risk 
factors for overdose, appropriate response to 
overdose, and administration of naloxone. OOPP 
could be designed like first aid or CPR 
(cardiopulmonary resuscitation) certification 
programs that require vetted instructors to 
educate the participants on standardized 
information. No matter who teaches the course or 
where one takes the course, each participant will 
walk away with the same knowledge and abilities 
regarding opioid overdoses and naloxone 
administration. Again, this is where athletic 
trainers can come in and use the information and 
skills they have gained in their continuing 
education course to teach and carry out the 
OOPPs. The systematic review highlights a need 
for OOPPs. It explains that opioid overdose is 
common, and naloxone is efficient and safe in 
reversing opioid overdoses.  Although these data 
are not methodologically sound, this guiding 
systematic review  identifies a trend towards 
OOPPs having the potential to decrease 
morbidity and mortality with an opioid overdose.  

CLINICAL BOTTOM LINE 

Opioid overdose prevention programs have 
worked towards reversing opioid overdoses, but 
research has reported mixed findings for its 
overall effectiveness in reducing the number of 
opioid incidences. This current systematic review 

was not able to determine this general 
effectiveness because of the lack of consistent 
measures and methodological limitations; 
however, the chief finding presented throughout 
the articles was that OOPPs were effective, 
specifically in the treatment of an opioid overdose 
and the administration of naloxone. 

Evidence in this review detected that heroin was 
the most frequently reported drug before an 
overdose; however, the leading cause cited was 
opioids.24 This fact is essential to health care 
providers, since many injuries are prescribed with 
opioid analgesics to reduce injury pain. Because 
of this athletes are an at risk population for the 
misuse of these prescription opioids. Athletic 
trainers are suggested to monitor post-operative 
patients, or any patient given opioids, and check-
in on their pain levels. The patient should not be 
reliant on opioids long term, so there should be a 
plan of action and timeline for gradually waning 
the patient off prescription pain relievers. The 
literature also did confirm that the majority of 
OOPP participants used non-recommended 
strategies, such as not call emergency medical 
services for an overdose. This is a factor that 
athletic trainers should emphasize in educating 
their patients, whether they believe medical 
assistance is needed or not, because there could 
be medical complications from the restricted 
respiration occurring in an overdose.23,24 The fear 
of police was indicated as the main reason for not 
preparing; however, the studies displayed more 
positive interactions than negative.16,17 Athletic 
trainers should direct attention to the prolonged 
medical issues an overdosed individual could have 
and attempt to ease the fear of utilizing EMS 
personnel. 21,22 

It is key that athletic trainers, much like the OOPP, 
are able to prevent, recognize, and respond to 
opioid overdose using pharmacological and non-
pharmacological interventions. We suggest that 
athletic trainers consider taking an OOPP, or a 
formal opioid overdose training course, if 



Community Opioid Overdose Prevention and Naloxone Distribution Programs: An Evidence-to-Practice Review 
 

 

38 
Copyright © by Indiana State University                                                                                Clinical Practice in Athletic Training  
All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 2 – September 2021 
 

unfamiliar with the management techniques 
described in this review. Additionally, athletic 
trainers can play a role in preventive efforts by 
spreading opioid overdose information to their 
population, including signs and symptoms of 
overdose, red flags to look out for, how to 
recognize an overdose, and how to respond if 
they are the non-medical bystander in an 
overdose situation. If opioid overdose education 
was accessible, or even mandatory prior to sport 
participation, for athletes and parents, then such 
education could improve the awareness and 
discourage opioid abuse. With the knowledge on 
how to deal with an opioid overdose, athletes can 
offer life-saving assistance in responding to a 
family member’s or roommates’ overdose 
situation. An athletic trainer should distinguish how 
to respond with or without a naloxone kit present, 
so individuals are prepared for both scenarios. 
Overall, there is evidence that supports OOPPs 
may benefit how to effectively handle an 
overdose situation. However, research is needed 
on this subject with more of a standard instrument 
for measuring how well these programs assist their 
participants in managing a drug overdose.  

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All rights reserved. ISSN Online 2577-8188                                                                     Volume 4 – Issue 2 – September 2021 
 

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https://dx.doi.org/10.2105%2FAJPH.2008.146647
https://dx.doi.org/10.2105%2FAJPH.2008.146647
https://doi.org/10.1136/bmj.f174
https://doi.org/10.1007/s11524-010-9495-8
https://doi.org/10.1007/s11524-010-9495-8
https://doi.org/10.1300/j069v25n03_11
https://doi.org/10.3109/09687637.2012.658104
https://doi.org/10.3109/09687637.2012.658104
https://doi.org/10.1016/j.drugpo.2008.03.002
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https://doi.org/10.1111/j.1360-0443.2008.02314.x
https://doi.org/10.1111/j.1360-0443.2008.02314.x
https://doi.org/10.1186/1477-7517-6-26
https://doi.org/10.1186/1477-7517-6-26
https://doi.org/10.3109/09687630802530712
https://doi.org/10.3109/09687630802530712
https://doi.org/10.1186/1477-7517-5-2
https://doi.org/10.1186/1477-7517-5-2
https://doi.org/10.1007/s10900-012-9591-7
https://doi.org/10.1007/s10900-012-9591-7
https://caate.occutrain.net/wp-content/uploads/2014/01/2012-Professional-Standards.pdf
https://caate.occutrain.net/wp-content/uploads/2014/01/2012-Professional-Standards.pdf
https://caate.occutrain.net/wp-content/uploads/2014/01/2012-Professional-Standards.pdf
https://doi.org/10.1016/j.jsr.2012.08.009

	ABSTRACT

