Exploring willingness to engage with law enforcement among syringe service program participants in New York City

BackgroundIn New York City (NYC), 1,487 unintentional overdose deaths occurred in 2017, largely driven by the presence of fentanyls in the illicit drug market. In response to fentanyl-involved overdoses, law enforcement entities both nationally and in NYC have taken a new interest in overdose events. This study explored attitudes toward and willingness to engage with police among NYC syringe service program (SSP) participants, a population likely to have had experiences with overdose and/or police.MethodsBetween March and July 2017, 332 surveys were conducted with a convenience sample of NYC SSP participants.ResultsMost respondents (76%) reported ever being arrested for a drug-related crime. Few respondents (5%) reported a previous arrest in the context of an overdose event. Of the 62 respondents who had witnessed an overdose in the previous 12 months, 25% had not called 911 because of concerns about law enforcement. Over half (51%) of all respondents reported they would not be willing to aid police in their investigation of the person who supplied the drugs.ConclusionPolice investigations of both fatal and non-fatal drug overdose events have the potential to exacerbate mistrust of law enforcement and discourage emergency medical service utilization among PWUD.     

Evaluation of the Staying Alive programme: training injection drug users to properly administer naloxone and save lives

BackgroundIn response to the high rates of opiate-related overdoses and deaths in the United States, a number of overdose prevention programmes have been implemented that include training drug users to administer naloxone, an opiate antagonist. The purpose of this study was to evaluate the Staying Alive (SA) programme in Baltimore, Maryland, which trained drug users to prevent and respond to opiate overdose using techniques including mouth-to-mouth resuscitation and administration of naloxone.MethodsParticipants for the SA programme were recruited from multiple locations by Baltimore City Health Department Needle Exchange programme staff. A 1-h training was conducted by two facilitators. Participants who successfully completed the programme were provided with a kit that contained naloxone. Participants in the evaluation study were enrolled prior to the training session. The present analysis includes 85 participants who completed a pre- and post-test evaluation survey.ResultsAt both time points, 43 participants reported having witnessed an overdose. Post-training, naloxone was administered by 19 with no reported adverse effects. Post-training, a greater proportion of participants reported using resuscitation skills taught in the SA programme along with increased knowledge specifically about naloxone.ConclusionsResults from this study provide additional evidence to support the effectiveness of overdose prevention training programmes that include skills building for drug users to administer naloxone.     

Circumstances of witnessed drug overdose in New York City: implications for intervention

Drug users frequently witness the nonfatal and fatal drug overdoses of their peers, but often fail to intervene effectively to reduce morbidity and mortality. We assessed the circumstances of witnessed heroin-related overdoses in New York City (NYC) among a predominantly minority population of drug users. Among 1184 heroin, crack, and cocaine users interviewed between November 2001 and February 2004, 672 (56.8%) had witnessed at least one nonfatal or fatal heroin-related overdose. Of those, 444 (67.7%) reported that they or someone else present called for medical help for the overdose victim at the last witnessed overdose. In multivariable models, the respondent never having had an overdose her/himself and the witnessed overdose occurring in a public place were associated with the likelihood of calling for medical help. Fear of police response was the most commonly cited reason for not calling or delaying before calling for help (52.2%). Attempts to revive the overdose victim through physical stimulation (e.g., applying ice, causing pain) were reported by 59.7% of respondents, while first aid measures were attempted in only 11.9% of events. Efforts to equip drug users to manage overdoses effectively, including training in first aid and the provision of naloxone, and the reduction of police involvement at overdose events may have a substantial impact on overdose-related morbidity and mortality.     

High occurrence of witnessing an opioid overdose in a sample of women who use heroin in Tanzania: Implications for overdose prevention

BackgroundOpioid overdose is preventable and reversible. To target overdose prevention training and naloxone distribution, it is important to understand characteristics of those people who use drugs most likely to witness an overdose. In this paper we report the proportion and characteristics of women who use heroin that have witnessed an opioid overdose in Dar es Salaam, Tanzania.MethodsWe conducted a cross-sectional survey with 200 women who use heroin. We fitted unadjusted and adjusted logistic regression models with witnessing an opioid overdose as the dependent variable and sociodemographic and drug use-related variables as independent variables.ResultsThe majority of participants (85%) reported having ever witnessed an opioid overdose. Age (adjusted Odds Ratio [aOR] = 1.09; 95% CI: 1.02–1.12), having ever attempted to stop heroin use (aOR = 11.27; 95% CI: 2.25–56.46), history of arrest (aOR = 3.75; 95% CI: 1.32–10.63), and spending time daily in places where people use drugs (aOR = 3.72; 95% CI: 1.43–9.64) were found to be independently associated with ever witnessing an overdose.ConclusionsFindings suggest the need for expanded access to naloxone to lay people and community and peer-based overdose prevention training in Tanzania, including the distribution of naloxone in settings with high drug use.     

Prevalence and disparities in opioid overdose response training among people who inject drugs,San Francisco: Naloxone training among injectors in San Francisco

BackgroundExpanding naloxone training stands to reduce opioid-related overdose deaths. The current study assessed the prevalence of overdose response training and use of naloxone among people who inject drugs (PWID).MethodsData were from a survey of PWID in San Francisco in 2018, recruited by respondent-driven sampling (RDS). Eligibility criteria were age over 18 years, injected non-prescribed drugs in the last year, San Francisco residence, and referral by another participant. Interviews collected demographic characteristics and injection-related behavior.ResultsThe sample (N=458) was majority male (67.5%) and over 45.5 years. Over three-fourths (76.0%) injected primarily opioids. Overall, 62.9% received overdose response training and 68.8% owned a naloxone kit. A majority (77.9%) had witnessed an overdose in the past year, of whom 55.8% used naloxone the last time they witnessed an overdose. Receiving overdose response training was significantly lower among persons of non-white race/ethnicity compared to whites (adjusted odds ratio [AOR] 0.43, 95% CI 0.27, 0.69) and higher among those who owned naloxone (AOR 6.29, 95% confidence interval [CI] 3.95, 10.02) and used syringe exchange programs (AOR 3.51, 95% CI 1.41, 8.79).ConclusionWhile the majority of PWID have had overdose response training, gaps and disparities persist in promotion of naloxone use.     

Correlates of seeking emergency medical help in the event of an overdose in British Columbia,Canada: Findings from the Take Home Naloxone program

BackgroundBritish Columbia (BC), Canada, is experiencing an unprecedented number of opioid overdoses mainly due to the contamination of illicit drugs with fentanyl and its analogues. Reluctance to seek emergency medical help (i.e., by calling 9-1-1) has been identified as a barrier to optimal care for overdose victims. This study aimed to identify the correlates of seeking help during an overdose event when naloxone was administered via BC’s Take Home Naloxone (THN) program.MethodsIn this cross-sectional study, we reviewed administrative records (from July 2015 to December 2017) about overdose events submitted by THN participants when they received their replacement naloxone kits (n = 2350). The primary outcome of the study was reported calling 9-1-1 and modified Poisson regression models were built to investigate the factors associated with help-seeking during an overdose event.ResultsMost overdose victims were men (69.0%) and >30 years old (61.5%). Overall, participants reported calling 9-1-1 in 1310 (55.7%) overdose events. In the multivariable model, the likelihood of calling 9-1-1 was significantly and positively associated with the overdose victim being male and receiving rescue breathing. The likelihood of calling 9-1-1 was significantly and negatively associated with the overdoses occurring in private residences and health regions other than Vancouver Coastal which delivers services to mostly urban residents.ConclusionOverall, medical help was sought for 55.7% of overdoses where naloxone was administered. Overdoses occurring among male victims as well as those receiving higher doses of naloxone and mouth-to-mouth rescue breathing were associated with a higher likelihood of help-seeking by responders. Future interventions need to encourage people who witness an overdose to seek emergency medical help.     

Drug users' experiences of witnessing overdoses: what do they know and what do they need to know?

The study investigated overdose attitudes and experiences among 155 attenders at an out‐patient drug clinic in south London. Almost half the sample (46.8%) had ever overdosed while 82.6% had witnessed overdoses, of whom 43 had witnessed overdose fatalities. However, this does not appear to have been a consequence of inaction, with most users reporting that they had attempted to resuscitate or assist the victim in a number of ways. Most participants also reported a reasonable awareness of the appropriate actions to take, were not deterred by fear of police sanction and managing reported that they would be willing to intervene in the future. Over a third were keen to receive training on managing overdose and that the majority would be willing to keep naloxone at home. This evidence supports previous research suggesting that addicts may be a valuable resource in strategies for reducing overdose fatalities through training and the dissemination of new drug technologies such as naloxone.     

Non-fatal opioid overdose,naloxone access,and naloxone training among people who recently used opioids or received opioid agonist treatment in Australia: The ETHOS Engage study

BackgroundOverdose is a major cause of morbidity and mortality among people who use opioids. Naloxone can reverse opioid overdoses and can be distributed and administered with minimal training. People with experience of overdose are a key population to target for overdose prevention strategies. This study aims to understand if factors associated with recent non-fatal opioid overdose are the same as factors associated with naloxone access and naloxone training in people who recently used opioids or received opioid agonist treatment (OAT).MethodsETHOS Engage is an observational study of people who inject drugs in Australia. Logistic regression models were used to estimate odds ratios for non-fatal opioid overdose, naloxone access and naloxone training.ResultsBetween May 2018-September 2019, 1280 participants who recently used opioids or received OAT were enrolled (62% aged >40 years; 35% female, 80% receiving OAT, 62% injected drugs in the preceding month). Recent opioid overdose (preceding 12 months) was reported by 7% of participants, lifetime naloxone access by 17%, and lifetime naloxone training by 14%. Compared to people receiving OAT with no additional opioid use, recent opioid, benzodiazepine (preceding six months), and hazardous alcohol use was associated with recent opioid overdose (aOR 3.91; 95%CI: 1.68–9.10) and lifetime naloxone access (aOR 2.12; 95%CI 1.29–3.48). Among 91 people who reported recent overdose, 65% had never received take-home naloxone or naloxone training.ConclusionsAmong people recently using opioids or receiving OAT, benzodiazepine and hazardous alcohol use is associated with non-fatal opioid overdose. Not all factors associated with non-fatal overdose correspond to factors associated with naloxone access. Naloxone access and training is low across all groups. Additional interventions are needed to scale up naloxone provision.     

A qualitative study of repeat naloxone administrations during opioid overdose intervention by people who use opioids in New York City.

BackgroundTake-home naloxone (THN) kits have been designed to provide community members (including people who use drugs, their families and/or significant others) with the necessary resources to address out-of-hospital opioid overdose events. Kits typically include two doses of naloxone. This 'twin-pack' format means that lay responders need information on how to use each dose. Advice given tends to be based on dosage algorithms used by medical personnel. However, little is currently known about how and why people who use drugs, acting as lay responders, decide to administer the second dose contained within single THN kits. The aim of this article is to explore this issue.MethodsData were generated from a qualitative semi-structured interview study that was embedded within a randomised controlled trial examining the risks and benefits of Overdose Education and Naloxone Distribution (OEND) training in New York City (NYC). Analysis for this article focuses upon the experiences of 22 people who use(d) opioids and who provided repeat naloxone administrations (RNA) during 24 separate overdose events. The framework method of analysis was used to compare the time participants believed had passed between each naloxone dose administered (‘subjective response interval’) with the ‘recommended response interval’ (2–4 minutes) given during OEND training. Framework analysis also charted the various reasons and rationale for providing RNA during overdose interventions.ResultsWhen participants’ subjective response intervals were compared with the recommended response interval for naloxone dosing, three different time periods were reported for the 24 overdose events: i. ‘two doses administered in under 2 minutes’ (n = 10); ii. ‘two doses administered within 2–4 minutes’ (n = 7), and iii. ‘two doses administered more than 4 minutes apart’ (n = 7). A variety of reasons were identified for providing RNA within each of the three categories of response interval. Collectively, reasons for RNA included panic, recognition of urgency, delays in retrieving naloxone kit, perceptions of recipients’ responsiveness/non-responsiveness to naloxone, and avoidance of Emergency Response Teams (ERT).ConclusionFindings suggest that decision-making processes by people who use opioids regarding how and when to provide RNA are influenced by factors that relate to the emergency event. In addition, the majority of RNA (17/24) occurred outside of the recommended response interval taught during OEND training. These findings are discussed in terms of evidence-based intervention and ‘evidence-making intervention’ with suggestions for how RNA guidance may be developed and included within future/existing models of OEND training.     

Overdoses among friends: drug users are willing to administer naloxone to others

The distribution of naloxone to heroin users is a suggested intervention to reduce overdose and death rates. However, the level of willingness of drug users to administer this medication to others is unclear. Drug users recruited from the community between January 2002 and January 2004 completed a structured interview that assessed topics including drug use, overdose history, and attitudes toward using overdose remedies to assist others. Of the 329 drug users, 82% had used heroin and 64.3% reported that they had injected drugs. Nearly two thirds (64.6%) said that they had witnessed a drug overdose and more than one third (34.6%) had experienced an accidental drug overdose. Most participants (88.5%) said that they would be willing to administer a medication to another drug user in the event of an overdose. Participants who had used heroin (p = .024), had injected drugs (p = .022), had witnessed a drug overdose (p = .001), or had a history of one or more accidental drug overdoses (p = .009) were significantly more willing to treat a companion who had overdosed. Drug users were willing to use naloxone in the event of a friend's overdose. Specific drug use and overdose histories were associated with the greatest willingness to administer naloxone.     

Brief overdose education can significantly increase accurate recognition of opioid overdose among heroin users

BackgroundIn an effort to increase effective intervention following opioid overdose, the New York State Department of Health (NYSDOH) has implemented programs where bystanders are given brief education in recognizing the signs of opioid overdose and how to provide intervention, including the use of naloxone. The current study sought to assess the ability of NYSDOH training to increase accurate identification of opioid and non-opioid overdose, and naloxone use among heroin users.MethodsEighty-four participants completed a test on overdose knowledge comprised of 16 putative overdose scenarios. Forty-four individuals completed the questionnaire immediately prior to and following standard overdose prevention training. A control group (n = 40), who opted out of training, completed the questionnaire just once.ResultsOverdose training significantly increased participants’ ability to accurately identify opioid overdose (p < 0.05), and scenarios where naloxone administration was indicated (p < 0.05). Training did not alter recognition of non-opioid overdose or non-overdose situations where naloxone should not be administered.ConclusionsThe data indicate that overdose prevention training improves participants’ knowledge of opioid overdose and naloxone use, but naloxone may be administered in some situations where it is not warranted. Training curriculum could be improved by teaching individuals to recognize symptoms of non-opioid drug over-intoxication.     

Decision-making by laypersons equipped with an emergency response smartphone app for opioid overdose

BackgroundTargeted naloxone distribution to potential lay responders increases the timeliness of overdose response and reduces mortality. Little is known, however, about the patterns of decision-making among overdose lay responders. This study explored heuristic decision-making among laypersons equipped with an emergency response smartphone app.MethodsUnityPhilly, a smartphone app that connects lay responders equipped with naloxone to overdose victims, was piloted in Philadelphia from March 2019 to February 2020. Participants used the app to signal overdose alerts to peer app users and emergency medical services, or respond to alerts by arriving at overdose emergency sites. This study utilised in-depth interviews, background information, and app use data from a sample of 18 participants with varying histories of opioid use and levels of app use activity.ResultsThe sample included 8 people who used opioids non-medically in the past 30 days and 10 people reporting no opioid misuse. Three prevailing, not mutually exclusive, heuristics were identified. The heuristic of unconditional signalling (“Always signal for help or backup”) was used by 7 people who valued external assistance and used the app as a replacement for a 911 call; this group had the highest number of signalled alerts and on-scene appearances. Nine people, who expressed confidence in their ability to address an overdose themselves, followed a heuristic of conditional signalling (“Rescue, but only signal if necessary”); these participants had the highest frequency of prior naloxone administrations. Eleven participants used the heuristic of conditional responding (“Assess if I can make a difference”), addressing an alert if they carried naloxone, were nearby, or received a signal before dark hours.ConclusionThe deployment of specific heuristics was influenced by prior naloxone use and situational factors. Success of overdose prevention interventions assisted by digital technologies may depend on the involvement of people with diverse overdose rescue backgrounds.     

Family carers and the prevention of heroin overdose deaths: Unmet training need and overlooked intervention opportunity of resuscitation training and supply of naloxone

Aim: To assess (a) carers' experiences of witnessing overdose; (b) their training needs; and (c) their interest in receiving training in overdose management.

Design: Postal questionnaire distributed through consenting participating local carer group co-ordinators in England.

Sample: 147 carers attending local support groups for friends and families of drug users.

Findings: Carers were usually parents (80%); 89% were currently caring for a heroin user of whom 49% had already had an overdose (93% involving opiates). One third had witnessed heroin being used, and 31 had witnessed an overdose. For eight carers, there had already been a death from drug overdose. There was poor knowledge of how to manage an overdose. Only a quarter had received advice on overdose management (26%) and only one third knew of the opiate antagonist naloxone (33%). The majority (88%) wanted training in overdose management, especially in emergency naloxone administration (88%). Interest in training did not differ according to carer type nor previous overdose experience.

Conclusion: We found evidence of an extensively overlooked carer population, many of whom have already been faced with an overdose situation and yet have received minimal training. We also found high levels of interest in receiving overdose training, in particular, in emergency naloxone administration.     

A descriptive study of racial and ethnic differences of drug overdoses and naloxone administration in Pennsylvania

IntroductionDrug overdose is a significant public health problem, yet little is known about racial/ethnic differences in drug overdose rates and/or in responses to a drug overdose following naloxone administration. This paper examines differences in rates of survivorship, response, revival and administration of naloxone by race and ethnicity among those who experienced a drug overdose in Pennsylvania between January 1, 2018 and December 31, 2019. Spatio-temporal variations in drug overdose locations were examined to facilitate understanding of service development, planning, and delivery of effective treatment need.MethodsTen thousand two hundred and ninety drug overdose incidents were analyzed from the Pennsylvania Overdose Information Network (ODIN). The ODIN is a centralized repository that contains information on drug overdoses victims including age, gender and race/ethnicity, naloxone administrations and survivorship, drug(s) suspected of causing the overdose, victim outcomes (e.g. hospitalizations and arrests) and average naloxone dosage per victim. Between group differences were tested using χ2 -tests of independence. Multivariate logistic regression was used to estimate the predicted probability of survivorship according to victim characteristics. All statistical analyses and mapping were performed using the R statistical programming environment.ResultsAbout eighty-seven percent of drug overdose response victims were white, and seventy-one percent were between the ages of 20–39. White females were more likely to receive an overdose response compared to black or Hispanic females. A non-opioid was indicated more frequently in overdoses involving black victims compared to either whites or Latinos. Latinos and blacks were more likely to survive a drug overdose. However, following naloxone administration, no racial or ethnic differences in survivorship were noted. Differences in responsiveness to naloxone and transitions to care following the drug overdose event were also found. Finally, overdoses among Blacks and Latinos demonstrated a stronger spatial patterning across counties compared to whites.ConclusionsThis study found a significant, disparate impact of race/ethnicity on fatal drug overdoses when naloxone is not administered. Further, individuals who were administered naloxone and subsequently received medical care in a hospital experienced lower drug-related mortality, suggesting that first responders are critical intervention points for individuals in need of medical treatment following a drug overdose. However, while naloxone administration is a necessary first step in the recovery process, longitudinal pathways towards treatment are critical to stem the drug overdose crisis.     

Book Reviews

Aim: To assess (a) carers’ experiences of witnessing overdose; (b) their training needs; and (c) their interest in receiving training in overdose management.

Design: Postal questionnaire distributed through consenting participating local carer group co-ordinators in England.

Sample: 147 carers attending local support groups for friends and families of drug users.

Findings: Carers were usually parents (80%); 89% were currently caring for a heroin user of whom 49% had already had an overdose (93% involving opiates). One third had witnessed heroin being used, and 31 had witnessed an overdose. For eight carers, there had already been a death from drug overdose. There was poor knowledge of how to manage an overdose. Only a quarter had received advice on overdose management (26%) and only one third knew of the opiate antagonist naloxone (33%). The majority (88%) wanted training in overdose management, especially in emergency naloxone administration (88%). Interest in training did not differ according to carer type nor previous overdose experience.

Conclusion: We found evidence of an extensively overlooked carer population, many of whom have already been faced with an overdose situation and yet have received minimal training. We also found high levels of interest in receiving overdose training, in particular, in emergency naloxone administration.     

What heroin users tell us about overdose

This study describes overdose experiences of heroin users, both the overdoses they themselves experienced, as well as those that they witnessed. A structured interview was performed with 101 current heroin users in Albuquerque, New Mexico from January 7, 2002 to February 26, 2002. Heroin-related overdoses were found to be common in this sample of heroin users. Three or more persons were reported to be present during 80 of the 95 most recently witnessed overdoses. An ambulance was called in only 42 of the 95 witnessed overdoses. Seventy-five percent of the respondents who witnessed an overdose stated concern over police involvement was an important reason for delay or absence of a 911 call for help. One hundred of the 101 respondents reported willingness, if trained, to use rescue breathing and to inject naloxone to aid an overdose victim. New methods need to be found to reduce heroin overdose death. Scientific studies are needed on the efficacy of take-home naloxone.     

The impact of take-home naloxone distribution and training on opiate overdose knowledge and response: An evaluation of the THN Project in Wales

Aims: To determine the impact of naloxone training on knowledge of opiate overdose and confidence and willingness to take appropriate action and to examine the use of naloxone and other harm-reduction actions at the time of overdose events. Methods: The evaluation was based on a repeated-measure design, whereby clients were tested before and after training. In total, 521 opiate users and four non-opiate users, drawn from five community sites (362) and three prison locations (163), completed pre- and post-test self-completed questionnaires. Actions taken at the time of overdose events by the naloxone group and a comparison group were compared using forms completed by agency staff. Findings: Knowledge about how to recognise and respond to overdose events increased among trainees across all measures. So too did perceived confidence in responding to them and willingness to carry out the recommended procedures. Over the course of the evaluation, there were 28 recorded uses of naloxone, resulting in 27 recoveries and one fatality. Conclusions: The study has shown that training in overdose management and the use of naloxone can bring about significant improvements in knowledge and willingness to take action. THN trainees also demonstrated that they were able to use naloxone successfully in overdose events.     

Evaluation of an overdose prevention and response training programme for injection drug users in the Skid Row area of Los Angeles,CA

BackgroundFatal opioid overdose is a significant cause of mortality among injection drug users (IDUs).MethodsWe evaluated an overdose prevention and response training programme for IDUs run by a community-based organisation in Los Angeles, CA. During a 1-h training session participants learned skills to prevent, recognise, and respond to opioid overdoses, including: calling for emergency services, performing rescue breathing, and administering an intramuscular injection of naloxone (an opioid antagonist). Between September 2006 and January 2008, 93 IDUs were trained. Of those, 66 (71%) enrolled in the evaluation study and 47 participants (71%) completed an interview at baseline and 3-month follow-up.ResultsTwenty-one percent of participants were female, 42% were white, 29% African American, and 18% Latino. Most were homeless or lived in temporary accommodation (73%). We found significant increases in knowledge about overdose, in particular about the use of naloxone. Twenty-two participants responded to 35 overdoses during the follow-up period. Twenty-six overdose victims recovered, four died, and the outcome of five cases was unknown. Response techniques included: staying with the victim (85%), administering naloxone (80%), providing rescue breathing (66%), and calling emergency services (60%). The average number of appropriate response techniques used by participants increased significantly from baseline to follow-up (p < 0.05). Half (53%) of programme participants reported decreased drug use at follow-up.ConclusionOverdose prevention and response training programmes may be associated with improved overdose response behaviour, with few adverse consequences and some unforeseen benefits, such as reductions in personal drug use.