Taking seriously the stories surrounding the opioid crisis may seem nothing more than a distraction from the real problem at hand -- armchair criticism, or worse, ‘committing sociology’ in a time when urgent response, and the evidence base to justify it, is the only justifiable action. But confronting such stories as the urban legends that they are can help public health leaders to understand why such stories arise and to meet the needs of the people propagating them. In doing so, public health leaders may also play a role in drawing attention to the broader social problems within which the overdose crisis has manifested, including under-funded response systems, the growing housing crisis, and of course, the ongoing discrimination and criminalization of people who use drugs.

A challenge for those working in public health communications in the opioid crisis is formulating how to respond to urban legends in the community. As a field, public health embraces evidence-informed policy and messaging: it can therefore seem natural to counter urban legends with facts or to dismiss them entirely in an effort to attenuate their spread. But, learning from the scholarship on urban legends, we suggest that there is value in identifying the needs that these stories meet for the public and for emergency medical responders. Doing so creates a broader evidence base of sociological knowledge capable of informing a response that addresses and validates these needs.

For the non-drug using public, a key need met by urban legends about naloxone is to make sense of the risks they face by creating a distinction between themselves and the people at highest risk of overdose. The result is to cast people who use drugs as deserving of overdose and death by making them appear irresponsible and unappreciative of efforts directed to help them, and by contrast to frame people who do not use drugs as safe and as deserving of health care resources. The context of the “War on Drugs,” in which drug use is framed as a personal or moral failing rather than a reaction to social conditions, underpins and reinforces this function of urban legends. In a rapidly changing risk environment (i.e. the micro and macro level spaces where physical and social factors interact to produce risk [13]), public health messaging can address the need to feel a sense of certainty and safety – for example, by accurately characterizing the risks associated with prescribed vs illegal opioids [14]. At the same time, the public health response should name and work to counter stigma against people who use drugs through respectful language [15] and by supporting and highlighting the contributions of people who use drugs and their organizations to public health efforts [16,17,18].

For first responders, from whom some of these legends have reached the media, naloxone urban legends should be interpreted in light of their changing role in the opioid overdose response. With the vastly increased number of overdoses, first responders have been subject to incredible pressures and trauma. Within a system that is so overwhelmed, such stories may very well be a way of making sense of an unsensible scene, or even a cry for help, whether for more resources to increase the front line workforce or for the supports needed to ensure workers are supported when such traumas overwhelm them. As well, the status of naloxone has changed from a prescription medication only used by health professionals, including emergency medical personnel, to one distributed to firefighters, police, librarians, teachers, people who use drugs themselves, and bystanders. The resulting change in scope of practice and in status for first responders as well as the responsibilization of the wider public should therefore be an area of attention in interpreting urban legends, particularly when these stories serve to reinforce the authority of health professionals as the most responsible users of naloxone.

Our call to take urban legends seriously needs especially to be heard from those who put them into the public arena in the first place. For the journalists and reporters mired in a world of clickbait media, the persistent pressure to ‘keep the story going’ feeds a public appetite for ever-more evocative plot twists. Public health has an important role to play in improving media literacy about the complex circumstances that surround the overdose crisis, including the health consequences of further marginalizing drug users.

For user networks, another power of urban legends is to undermine the culture of peer support that has characterized the street response to the epidemic. Public health has the power to humanize the crisis and work to ensure that support groups and activist organizations of people who use drugs are given the social license to operate without political sanction.

To conclude, we offer two modest recommendations for future consideration of the role of urban legends in public health. First, we suggest public health leaders find ways to raise professional awareness of the social function of urban legends and the role that they play in helping listeners to contend with complexity, emotion, and uncertainty. This suggestion may be of particular utility as practitioners contend with urban legends about transdermal fentanyl exposure risks to first responders [19], children [20], and funeral home workers [21]. Second, we echo a long chorus of calls to broaden the knowledge base of evidence-informed public health and ensure that our practitioners draw on the expertise of colleagues in the social sciences and humanities [22], in order to understand the social complexity within which public health operates and better anticipate the unforeseen consequences of our interventions.