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Overview

Naloxone is an FDA approved medication used to undo overdose from prescription opioids, fentanyl, heroin, and other drugs (1). Naloxone has a reported success rate between 95-98%, making accessibility to the medication vital in the present U.S. overdose crisis (2).Naloxone is sold in pharmacies as a nasal spray, so all domestic populations should be able to easily discover and access the medication. However, there is inadequate Naloxone stock and distribution in areas heavily populated by racial minorities. This creates large racial disparities in Naloxone access, with Black, Latinx, and Indigenous populations having lower access to the medication (3) (4). Addressing these disparities is vital for alleviating the U.S. overdose crisis, as these three racial populations comprise the highest domestic drug overdose fatality rates (5). Wider implementation of Good Samaritan laws can alleviate the Black and Latinx disparities, while emphasizing demand-driven Naloxone distribution and stock in policy can alleviate the Indigenous disparity (6) (7).

Black and Latinx Disparity

In the U.S., public access to emergency medical services are ensured under the Emergency Medical Treatment & Labor Act (EMTALA) (8). Yet Naloxone – an emergency relief medication – is inaccessible for many racial minorities. Studies find that pharmacies in predominately Black and Latinx residential areas fail to keep Naloxone stocked relative to thewell-stocked pharmacies in nearby white residential areas (5). Such inadequate Naloxone stock leaves racial minorities unable to discover and subsequently purchase the medication when needed. As a result, there is a wide racial disparity in Naloxone awareness, with a 2024 studyfinding that white adults have nearly twice the awareness of Naloxone’s existence and purpose as Black and Latinx adults (3). Given that overdose fatality rates increased in Black populations by nearly 250% and in Latinx populations by over 170% between 2015-2022, improving Naloxone access and awareness within both racial groups is vital for alleviating the U.S. overdose crisis(9).

Indigenous Disparity

Indigenous populations also face disparity in Naloxone access. A study conducted in a rural Northern Midwest region of the U.S. found that only 24% of Indigenous individuals in the area had access to Naloxone, with only one Naloxone distribution program serving the entireregion (4). The rural nature of Indigenous tribal lands is a pattern consistent across the U.S., as Western urbanization has pushed Indigenous populations out of mainstream regions (10). This means that Indigenous tribes are not at fault for residing in areas with low Naloxone distribution.In fact, both qualitative and quantitative reviews have found that the interconnected nature of Indigenous tribes facilitates excellent healthcare redistribution (11). But Indigenous tribes cannot redistribute Naloxone if the medication is not made consistently available to them.So, Indigenous disparity in Naloxone access is an issue of inadequate distribution to rural tribal areas rather than a fault of Indigenous tribes. And given that Indigenous populations have the highest drug overdose fatality rate amongst racial groups in the U.S., mending this disparity to alleviate the U.S. overdose crisis is vital (5).

Interventions

​It is then evident that wide racial disparities in Naloxone access exist, especially relative to racial needs for the medication. To best address these racial disparities in Black, Latinx, and Indigenous access, two key interventions should take place. The first intervention is wider implementation of Good Samaritan laws, which targets providing increased access to Black and Latinx populations. The second intervention is emphasizing demand-driven Naloxone distribution and stock in policy, which targets providing increased access to Indigenous populations. However, these two interventions are not mutually exclusive to their targeted racial groups, as both interventions can increase Naloxone access within all racial groups to alleviate the broader U.S. overdose crisis.

​Many racial injustices, including inadequate Naloxone pharmacy stock in predominately Black and Latinx residential areas, erode Black and Latinx trust in U.S. healthcare and governmental services. Other racial injustices that contribute to this distrust include racial profiling by law enforcement and racial neglection by healthcare entities (12). These injustices contribute to systemic racism as a driving factor in the disproportionate overdose fatality rates seen in racial minority populations (9). To prevent distrust from deterring Black and Latinx populations from requesting Naloxone or calling 911, Good Samaritan laws should be widely implemented. In a comprehensive study of all 50 U.S. states spanning 14 years, Good Samaritan laws facilitated a 26% reduction in drug overdose fatality among Black populationsand a 16% reduction in drug overdose occurrence among Latinx populations (6). Thus, wider implementation of Good Samaritan laws can encourage utilization of healthcare resources, including Naloxone, to alleviate racially disproportionate drug overdose fatality rates.

To address inadequate Naloxone distribution in rural Indigenous tribal regions, policy should emphasize demand-driven distribution and stock. Sweden’s rural Region Västerbotten is a potential blueprint for this policy shift. Region Västerbotten utilizes a network of civil society, public institutions, and businesses to collectively improve distribution of healthcare resources to populations in the rural region (7) (p. 5). This way, healthcare resources like medication reach those in need regardless of their proximity to hospitals and pharmacies. U.S. policy strategy can benefit from emphasizing similar demand-driven coalition to ensure Indigenous populations have access to enough Naloxone relative to their heightened need for it.

Conclusion

​Implementing more Good Samaritan law and demand-driven policy can alleviate racial disparities in Naloxone access. In doing so, it can address the broader U.S. overdose crisis by increasing general access and distribution of the medication to all populations. But these interventions leave two key factors unconsidered. First is barriers to Naloxone access that are specific to Asian populations. The underlying factors of overdose rates and healthcare accessamong Asian populations are drastically different from the factors among Black, Latinx, and Indigenous populations. So, any specific strategies for improving Naloxone access among Asian populations are beyond the scope of this paper. Second is barriers to adopting demand-driven coalition inspired by rural Region Västerbotten. Namely, shifting U.S. governmental interest away from capitalistic interests surrounding mainstream cities and toward healthcare demands across both rural and mainstream regions. Shifting U.S. interest toward rural regions is then an extensive issue beyond the scope of this paper. Both unconsidered factors should be tackled with intervention so the U.S. overdose crisis, characterized by racial disparities in Naloxone access, can be effectively addressed.

References

1.​ Health D of P. California Department of Public Health [Internet]. [cited 2026 Mar 24]. Available from: https://www.cdph.ca.gov/Programs/CCDPHP/sapb

2.​ Fischer LS, Asher A, Stein R, Becasen J, Doreson A, Mermin J, et al. Effectiveness of naloxone distribution in community settings to reduce opioid overdose deaths among people who use drugs: a systematic review and meta-analysis. BMC Public Health. 2025 Mar 25;25(1):1135. doi:10.1186/s12889-025-22210-8

3.​ Black, Hispanic, And Asian Adults In The US Had Substantially Lower Engagement On The Naloxone Care Cascade, 2024 | Health Affairs Journal. Health Aff (Millwood) [Internet]. [cited 2026 Mar 24]. Available from: https://www.healthaffairs.org/doi/10.1377/hlthaff.2025.00263

4.​ Schneider KE, Allen ST, O’Rourke A, Reid MC, Conrad M, Hughes P, et al. Examining naloxone access and interest in secondary naloxone distribution on an American Indian Reservation in the Northern Midwest of the United States. Drug Alcohol Depend Rep. 2024 Dec 1;13:100285. doi:10.1016/j.dadr.2024.100285

5.​ Products – Data Briefs – Number 522 – December 2024 [Internet]. 2024 [cited 2026 Mar 24]. Available from: https://www.cdc.gov/nchs/products/databriefs/db522.htm doi:10.15620/cdc/170565

6.​ McClellan C, Lambdin BH, Ali MM, Mutter R, Davis CS, Wheeler E, et al. Opioid-overdose laws association with opioid use and overdose mortality. Addict Behav. 2018 Nov 1;Prevention and Treatment of Opioid Overdose and Opioid-Use Disorders86:90–5. doi:10.1016/j.addbeh.2018.03.014

7.​ Berggren P. ACCESS TO RURAL SERVICES BY STRENGTHENING PRIMARY CARE WITH DIGITAL TOOLS IN REMOTE AREAS OF SWEDEN.

8.​ Emergency Medical Treatment & Labor Act (EMTALA) | CMS [Internet]. [cited 2026 Mar 24]. Available from: https://www.cms.gov/medicare/regulations-guidance/legislation/emergency-medical-treatment-labor-act

9.​ Smith MK, Planalp C, Bennis SL, Stately A, Nelson I, Martin J, et al. Widening Racial Disparities in the U.S. Overdose Epidemic. Am J Prev Med. 2025 Apr;68(4):745–53. doi:10.1016/j.amepre.2024.12.020 PubMed PMID: 39736388; PubMed Central PMCID: PMC12270509.

10. 2021-22 Rural Humanities is Radically Indigenous | Rural Humanities [Internet]. 2021 [cited 2026 Mar 28]. Available from: https://rural.as.cornell.edu/news/2021-22-rural-humanities-radically-indigenous

11. Bourke S, Wright A, Guthrie J, Russell L, Dunbar T, Lovett R. Evidence Review of Indigenous Culture for Health and Wellbeing. Int J Health Wellness Soc. 2018 Jan 1;8:11–27. doi:10.18848/2156-8960/CGP/v08i04/11-27

12. Crump AA, Ransome Y, Castillo WC, Kawachi I, Jones SMW, Reeve BB, et al. Identifying High-Priority Ecological-Level Indicators of Structural Racism in Black and Hispanic/Latino Communities. J Racial Ethn Health Disparities. 2026 Feb 9. doi:10.1007/s40615-026-02889-0

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Overview

The period immediately following release from incarceration represents a critical “cliff edge” for opioid overdose, with risk levels significantly higher than the general population. Despite known interventions, U.S. reentry remains fragmented, relying on discretionary programs rather than standardized clinical safeguards.

This paper proposes a “safe release standard”, a non-negotiable discharge bundle including MOUD initiation, take-home naloxone, and “warm” handoffs to community care.

By shifting the framing from elective programming to a health services design problem, jurisdictions can leverage new federal Medicaid opportunities to ensure continuity. Transitioning to a standardized, measurable protocol is essential to convert predictable risks into manageable public health outcomes.

Having a Safe Release Standard from Prisons in the United States

Opioid overdose is a leading cause of death in the period immediately after release from incarceration, driven by reduced opioid tolerance, interrupted treatment, unstable housing, and abrupt transitions in care [1,2].

In a landmark cohort study, the first two weeks after release from prison were associated with a markedly elevated risk of death from drug overdose compared with the general population [1]. More recent analyses that track both fatal and nonfatal events similarly show that overdose risk concentrates in the early post-release window and is closely tied to gaps in continuity of addiction care [2].

This pattern is not only a clinical problem affecting individuals. Instead, it reflects a failure in how prison-to-community transitions are designed.

One clear improvement is to establish a safe release standard for prison systems, defined as a minimum set of evidence-based steps that must occur before release for people at risk of opioid overdose.

In practice, this is analogous to a discharge bundle used in hospitals: a standardized pathway that ensures the highest-risk transition is supported by basic safeguards, rather than left to ad hoc decision-making.

A safe release standard does not require new pharmacology or novel clinical insights. It simply applies what is already known about overdose prevention and treatment continuity, and it makes those practices routine so that a person’s safety does not depend on the facility they leave, the county they return to, or whether a single staff member has time to coordinate reentry.

International guidance from the World Health Organization and the United Nations Office on Drugs and Crime emphasizes continuity of evidence-based treatment for drug dependence in custodial settings and linkage to care in the community [4].

In the United States, correctional health guidance increasingly frames medications for opioid use disorder (MOUD) and reentry planning as implementation problems rather than elective programming, highlighting service delivery models, staff training, and operational steps needed for consistent uptake [5]. This shift in framing matters because it positions safe release as a health services design problem, where the key question is not whether reentry support is desirable, but what minimum standard of transition should be considered safe.

The United Kingdom offers a useful example of how system design can standardize outcomes when risk is concentrated around a predictable transition. Scotland’s national take-home naloxone program is explicitly structured to reach people at high risk of opioid death, including those leaving prison, and has been evaluated using opioid-related deaths within weeks of prison release as a core outcome [7].

The significance of this model is not that the United States must adopt Scotland’s governance structure or commissioning arrangements, but that it demonstrates feasibility: naloxone-on-release can be treated as a routine system function, supported by written protocols and measurable targets, rather than as a discretionary add-on.

The baseline U.S. system stands in sharp contrast. Many jurisdictions still do not provide comprehensive MOUD access in custody, and reentry coordination varies widely across facilities and counties [3,5]. Even where treatment is initiated, continuity can break at the point of release because of administrative barriers, lack of identification, lapsed insurance, limited appointment availability, transportation constraints, and stigma in downstream settings.

The result is a fragmented pathway in which the highest-risk period is managed with the least reliable infrastructure.

A safe release standard would therefore treat release as a structured clinical handoff and would make a small number of steps non-negotiable for people at risk of opioid overdose.

At a minimum, this includes early identification of OUD and overdose risk, with a clear discharge plan that travels with the patient; initiation or continuation of MOUD during incarceration paired with a plan for uninterrupted dosing or rapid follow-up after release; provision of take-home naloxone at release with brief education that is realistic and non-stigmatizing; benefits activation and “warm” linkage to community care so that treatment and medications are actually accessible in the first days after release; and basic release logistics designed around service availability, such as release timing that permits pharmacy access, clinic intake, and transportation.

The goal is not to create an idealized reentry program. It is to ensure that the system reliably delivers the minimum conditions for a safer transition.

Not only does standardization improve safety, but it also enables accountability and iterative improvement.

When safe release is framed as a defined bundle, systems can track a small number of indicators that directly measure implementation: the proportion of people released with an active MOUD plan and confirmed follow-up; the proportion released with naloxone in hand; the proportion with insurance active on day of release; and the frequency of documented medication gaps across the transition. These measures convert a broad moral imperative into an operational agenda that can be audited and improved.

Experience with statewide correctional MOUD programs underscores why these components should be treated as standard rather than exceptional.

Implementation in Rhode Island’s unified jail and prison system, for example, has been associated with substantial reductions in post-incarceration overdose deaths, illustrating both feasibility and the potential for population-level impact when treatment is scaled and linked to reentry [8,9].

The mechanism is straightforward: people are more likely to survive the transition when treatment is available during incarceration and continuity is protected at release. The safe release standard builds on this insight by making continuity and linkage explicit design requirements rather than assumptions.

Recent federal policy developments also make standardization more plausible. The Medicaid Reentry Section 1115 Demonstration Opportunity is explicitly intended to improve care transitions by supporting coverage of certain pre-release services, thereby reducing discontinuity at the moment of release [6].

Financing does not solve implementation by itself, but it addresses one of the structural reasons reentry planning remains inconsistent: many of the necessary coordination tasks are time-consuming, require cross-system communication, and historically have not been reimbursed.

A safe release standard can therefore align clinical intent with practical capacity by pairing clear expectations with workable payment and accountability structures.

To that end, a health services improvement agenda for safe release in U.S. prison systems would build on existing evidence in three ways:

In a country where overdose risk is tightly linked to structural vulnerability, establishing a safe release standard offers a concrete way to redesign a predictable high-risk transition so that it functions as a true public health handoff rather than a cliff edge.

The evidence base already supports the core components: medications for opioid use disorder reduce overdose risk and improve continuity of care, and naloxone distribution is a pragmatic intervention for an acute high-risk window [5,7–9]. The remaining question is whether prison systems will treat these steps as optional programs that depend on local champions, or as the minimum standard required for safe release.

References

1. Binswanger IA, Stern MF, Deyo RA, et al. Release from Prison — A High Risk of Death for Former Inmates. N Engl J Med. 2007.

2. Hartung DM, et al. Fatal and non-fatal opioid overdose risk following release from incarceration. 2023.

3. The Pew Charitable Trusts. Opioid Use Disorder Treatment in Jails and Prisons. 2020.

4. United Nations Office on Drugs and Crime; World Health Organization. International Standards for the Treatment of Drug Use Disorders. 2020.

5. Substance Abuse and Mental Health Services Administration. Guidelines for Implementing Medications for Opioid Use Disorder Treatment in State Prisons. 2025.

6. Centers for Medicare & Medicaid Services. Medicaid Reentry Section 1115 Demonstration Opportunity. 2023.

7. Bird SM, McAuley A, Perry S, Hunter C. Effectiveness of Scotland’s National Naloxone Programme for reducing opioid-related deaths: a before versus after comparison. Addiction. 2016.

8. Green TC, et al. Postincarceration Fatal Overdoses After Implementing Medications for Addiction Treatment in a Statewide Correctional System. JAMA Psychiatry. 2018.

9. Clarke JG, et al. The First Comprehensive Program for Opioid Use Disorder in a Statewide Correctional System. Am J Public Health. 2018.