Response to Overdose Among Injection Drug Users

doi:10.1016/j.amepre.2006.04.002

American Journal of Preventive Medicine

Volume 31, Issue 3, September 2006, Pages 261-264

https://doi.org/10.1016/j.amepre.2006.04.002 Get rights and content

Background

Drug overdose is a leading cause of mortality among illicit drug users. This study characterizes responses to overdose among injection drug users (IDUs) in Baltimore, Maryland, and identifies factors associated with medically inappropriate response.

Methods

A cross-sectional survey was administered to 924 IDUs in an ongoing cohort study between August 2003 and September 2004. Self-reported experiences of witnessing overdose were obtained by structured interview. Multiple logistic regression identified associations between overdose information sources and medically inappropriate responses.

Results

Most IDUs (69.7%) reported ever witnessing an overdose. The most common responses were walking the victim around (70.8%), shaking them (64.9%), and inflicting pain (62.6%). One in four (25.8%) injected the victim with salt water. Two thirds (63.4%) called 911, but more than half delayed the call by 5 or more minutes. The most common reason cited for delaying or foregoing the 911 call was the belief that they could revive the victim themselves, followed by fear of police involvement. Most IDUs had received information on how to prevent or respond to an overdose, but most (73.2%) received this information from friends or other drug users. IDUs who got overdose information solely from lay sources were less likely to call 911 (adjusted odds ratio [AOR]=0.66, 95% confidence interval [CI]=0.46–0.94) and more likely to inject the victim with salt water (AOR=2.06, 95% CI=1.36–3.13) than IDUs who received no information at all. Injection drug users who received information from medical and social services providers only were less likely to delay the 911 call (AOR=0.35, 95% CI=0.22–0.72).

Conclusions

Inappropriate overdose responses are widespread among IDUs in Baltimore. Interventions that provide overdose education and reduce police response to overdose events may improve witness response and reduce mortality associated with drug overdose.

Introduction

Drug overdose is a leading cause of death among illicit drug users.1, 2, 3 Although death from overdose is rarely immediate, and prognosis is good if appropriate interventions are undertaken, there were 26,018 drug-induced deaths⁴ in the United States in 2002. An appropriate intervention is to call 911 immediately; however, only 13% to 68% of drug users reported calling for medical assistance the last time that they witnessed an overdose.5, 6, 7, 8, 9 Instead, witnesses often engaged in alternative interventions ranging from the relatively benign to the potentially dangerous.5, 7, 8, 10, 11

Overdose witnesses consistently cite fear of police involvement as a reason for foregoing medical assistance,5, 8, 11 but misinformation may also play a role.12, 13 Overdose responses among injection drug users (IDUs) were characterized in Baltimore MD, where per capita overdose mortality is among the highest in the United States (56.4 per 100,000).¹⁴ Barriers to calling 911 and the associations between overdose information sources and overdose responses were also identified.

Section snippets

Methods

Study subjects were participants in the AIDS Link to Intravenous Experiences (ALIVE) study, a prospective cohort study among IDUs in Baltimore, described elsewhere.15, 16 Between 1988 and 1989, some 2960 IDUs were recruited; they were aged ≥18 years, injected illicit drugs within the previous 11 years, and were AIDS-free at enrollment. In 1994, 1998, and 2000, an additional 419, 246, and 50 participants, respectively, were recruited. Participants returned semiannually for interviews, physical

Results

Of 924 subjects, the majority was black (92.9%) and male (67.1%). Median age was 47 years (interquartile range [IQR]=43–52). Overall, 644 IDUs (69.7%) reported witnessing one or more overdoses (median 3, IQR=2–5). For most (87.9%), it had been more than a year since they last witnessed an overdose.

The majority reported walking the overdose victim around (70.8%); shaking him/her (64.9%); calling 911 (63.4%); inflicting pain by pinching, slapping, hitting, or other methods (e.g., burning their

Discussion

Although the majority of studied IDUs had witnessed an overdose, few called 911 as their first response. Most engaged in inappropriate interventions before, or in lieu of, seeking emergency medical assistance. Interestingly, the primary reasons cited for delaying or foregoing a 911 call differed. Most IDUs who delayed the call did so because they believed that they could revive the victim, while those who avoided calling 911 most commonly cited concerns about police.

These findings suggest that

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Cited by (54)

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2023, International Journal of Drug Policy
The national overdose crisis is often quantified by overdose deaths, but understanding the traumatic impact for those who witness and respond to overdoses can help elucidate mental health needs and opportunities for intervention for this population. Many who respond to overdoses are people who use drugs. This study adds to the literature on how people who use drugs qualitatively experience trauma resulting from witnessing and responding to overdose, through the lens of the Trauma-Informed Theory of Individual Health Behavior.
We conducted 60-min semi-structured, in-depth phone interviews. Participants were recruited from six states and Washington, DC in March–April 2022. Participants included 17 individuals who witnessed overdose(s) during the COVID-19 pandemic. The interview guide was shaped by theories of trauma. The codebook was developed using a priori codes from the interview guide; inductive codes were added during content analysis. Transcripts were coded using ATLAS.ti.
A vast majority reported trauma from witnessing overdoses. Participants reported that the severity of trauma varied by contextual factors such as the closeness of the relationship to the person overdosing or whether the event was their first experience witnessing an overdose. Participants often described symptoms of trauma including rumination, guilt, and hypervigilance. Some reported normalization of witnessing overdoses due to how common overdoses were, while some acknowledged overdoses will never be “normal.” The impacts of witnessing overdose on drug use behaviors varied from riskier substance use to increased motivation for treatment and safer drug use practices.
Recognizing the traumatic impact of witnessed overdoses is key to effectively addressing the full range of sequelae of the overdose crisis. Trauma-informed approaches should be central for service providers when they approach this subject with clients, with awareness of how normalization can reduce help-seeking behaviors and the need for psychological aftercare. We found increased motivation for behavior change after witnessing, which presents opportunity for intervention.
National survey findings on law enforcement agency drug response practices, overdose victim outcomes, and Good Samaritan Laws
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The United States continues to experience unprecedented rates of overdose mortality. Addressing the overdose epidemic has been challenging for policy makers given the lack of effectiveness of existing drug control policy measures. More recently, the implementation of harm reduction-based policies such as Good Samaritan Laws has led to increasing scholarly attention aimed at evaluating their effectiveness at reducing the likelihood of criminal justice-related sanctions for individuals following an overdose incident. The results of these studies, however, have been mixed.
This study utilizes data from a nationally representative survey of law enforcement agencies designed to provide national information on services, policies, practices, operations, and resources of law enforcement drug response around overdoses to assess whether state Good Samaritan Laws reduce the likelihood of overdose victims being cited or being jailed following an overdose incident.
In general, findings indicate that although most agencies reported that overdose victims were not incarcerated or cited following an overdose incident, that this did not vary by whether agencies were in a state that had a GSL arrest protection for possession of controlled substances.
GSLs are often written in complex and confusing language that officers and people who use drugs do not fully understand, which may deter their being used for their intended purpose. Although GSLs are well-intentioned, these findings highlight the need for training and education for law enforcement and people who use drugs around the scope of these laws.
Good Samaritan laws and overdose mortality in the United States in the fentanyl era
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As of July 2018, 45 United States (US) states and the District of Columbia have enacted an overdose Good Samaritan law (GSL). These laws, which provide limited criminal immunity to individuals who request assistance during an overdose, may be of importance in the current wave of the overdose epidemic, which is driven primarily by illicit opioids including heroin and fentanyl. There are substantial differences in the structures of states’ GSL laws which may impact their effectiveness. This study compared GSLs which have legal provisions protecting from arrest and laws which have more limited protections.
Using national county-level overdose mortality data from 3109 US counties, we examined the association of enactment of GSLs with protection from arrest and GSLs with more limited protections with subsequent overdose mortality between 2013 and 2018. Since GSLs are often enacted in conjunction with Naloxone Access Laws (NAL), we examined the effect of GSLs separately and in conjunction with NAL. We conducted these analyses using hierarchical Bayesian spatiotemporal Poisson models.
GSLs with protections against arrest enactment in conjunction with a NAL were associated with 7% lower rates of all overdose deaths (rate ratio (RR): 0.93% Credible Interval (CI): 0.89–0.97), 10% lower rates in opioid overdose deaths (RR: 0.90; CI: 0.85–0.95) and 11% lower rates of heroin/synthetic overdose mortality (RR: 0.89; CI: 0.82–0.96) two years after enactment, compared to rates in states without these laws. Significant reductions in overdose mortality were not seen for GSLs with protections for charge or prosecution.
GSLs with more expansive legal protections combined with a NAL, were associated with lower rates of overdose deaths, although these risk reductions take time to manifest. Policy makers should consider enacting and implementing more expansive GSLs with arrest protections to increase the likelihood people will contact emergency services in the event of an overdose.
Investigating a bidirectional relationship between overdose and provision of injection initiation assistance among persons who inject drugs in Vancouver, Canada and Tijuana, Mexico
2021, International Journal of Drug Policy
Citation Excerpt :
Importantly, all overdoses reported in this study were non-fatal. This could be explained by an overdose being attended by harm reduction staff, emergency services, or peers possessing overdose education and naloxone distribution (OEND) training (Wheeler et al., 2015; Bowles & Lankenau, 2018; Koester et al., 2017; Wagner et al., 2010; Pollini et al., 2006; Tracy et al., 2005; Tobin, Davey, & Latkin, 2005). As such, supporting those who assist in injection initiation via a safer-injection “train-the-trainer” approach, coupled with OEND (Wheeler et al., 2015; Bowles & Lankenau, 2018; Coalition, 2021; Bennett et al., 2021), is suggested.
Individuals who initiate injection drug use often receive assistance from an injection-knowledgeable peer. Persons who assist peers in injection initiation events often inject frequently, which heightens overdose risk. As such, overdose and injection initiation events may be correlated. To explore a potential relationship, we assessed temporal associations between experiencing a non-fatal overdose and assisting others in initiating injection drug use among persons who inject drugs in two North American cities – Vancouver, Canada and Tijuana, Mexico.
From 2014 to 2018, this retrospective cohort study included people who inject drugs from Vancouver (n=1332) and Tijuana (n=666) who completed a baseline and six-month follow-up interview. Within each site, we assessed bidirectional temporal associations using two separate multivariable logistic regression models: for model 1, recent provision of injection initiation assistance (at six months) was the outcome and recent overdose (at baseline) was the exposure; for model 2, recent overdose (at six months) was the outcome and recent provision of injection initiation assistance (at baseline) was the exposure. Both models adjusted for potential confounders.
Vancouver-based participants reporting overdose at baseline had 163% greater odds of reporting provision of injection initiation assistance at follow-up (adjusted Odds Ratio [aOR] 2.63; 95% Confidence Interval [CI] 1.41–4.90); while participants reporting provision of injection initiation assistance at baseline had 89% greater odds of reporting a non-fatal overdose at follow-up (aOR 1.89; 95% CI 1.00–3.57). Among Tijuana-based participants, we did not observe a statistically significant association in either direction.
Findings in Vancouver suggest that injection initiation assistance and overdose are bidirectionally-associated phenomena. The present findings highlight the need for interventions that ensure that persons who provide injection initiation assistance are given overdose prevention support, both for themselves and for those they assist to initiate injection drug use. While our Tijuana-based results did not suggest a bidirectional relationship, preventative approaches should nonetheless be undertaken.
People, places, and stigma: A qualitative study exploring the overdose risk environment in rural Kentucky
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Though overdose rates have been increasing in US rural areas for two decades, little is known about the rural risk environment for overdoses. This qualitative study explored the risk environment for overdoses among young adults in Eastern Kentucky, a rural epicenter of the US opioid epidemic.
Participants were recruited via community-based outreach. Eligibility criteria included living in one of five rural Eastern Kentucky counties; being aged 18–35; and using opioids to get high in the past 30 days. Semi-structured interviews explored the rural risk environment, and strategies to prevent overdose and dying from an overdose. Interviews were transcribed verbatim and analyzed using constructivist grounded-theory methods.
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“Generally, you get 86′ed because you're a liability”: An application of Integrated Threat Theory to frequently witnessed overdoses and social distancing responses
2020, Social Science and Medicine
Citation Excerpt :
Fellow PWUDs are often witnesses and first responders to opioid overdoses (National Institutes of Drug Abuse [NIDA], 2019; Wheeler et al., 2014). Responses to witnessed overdoses by PWUDs have included injecting the person overdosing with salt or milk, placing ice on their genitals, placing the person in an ice bath or cold shower, or slapping the person or causing pain to stimulate them (Bowles and Lankenau, 2018; Koester, S., Mueller, S. R., Raville, L., Langegger, S., & Binswanger, I. A., 2017; Pollini et al., 2006; Tracy et al., 2005, Tobin et al., 2005; Wagner et al., 2019). In each of these studies, participants mentioned reluctance, hesitation, or refusal to contact 911 due to prior bad experiences with police during overdose events, such as incarceration.
While rates of opioid overdose deaths in North American have increased exponentially in recent years, most overdoses are not fatal, especially when witnesses are present and can intervene. Previous research has found that some people who use drugs [PWUDs] trained in overdose response might cut social ties with frequent overdosers, leading to more solitary opioid use and risk of death if someone overdoses alone. To examine the phenomenon of social distancing of people who overdose frequently, we used data from fifty-two in-depth qualitative interviews collected in Southern California with PWUDs who had recently witnessed an opioid overdose. Transcripts were reviewed and coded thematically, using the Integrated Threat Theory (ITT) to conceptualize the observed phenomenon. ITT outlines how realistic and symbolic threats are experienced by a group. We found that while some participants acknowledged the role of adulterated street drugs in overdoses, individualized blame was nonetheless imposed. Accusations of careless drug use practices fostered negative stereotyping towards frequent overdosers. This was attributed to the need to summon 911 for rescue, which often resulted in police dispatch. The intergroup relationship between police and PWUDs is precarious as police pose realistic threats onto PWUDs - such as incarceration, eviction, and manslaughter charges - leading to intragroup anxiety among PWUDs about future overdose events, and labelled frequent overdosers as liabilities. These threats, and inter/intra-group conflict, explained one reason how and why non-fatal overdoses led to social distancing events. People who overdose frequently were also accused of breaking the norm of drug user surreptitiousness; a symbolic threat that endangered the group due to police exposure. Social distancing might dampen exposure to the protective effect of peer-led interventions such as take-home naloxone programs, increasing risk of overdose death. This phenomenon highlights how intergroup dynamics are driving intragroup processes. Suggestions for tailoring public health interventions are discussed.

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Brief reportResponse to Overdose Among Injection Drug Users

Background

Methods

Results

Conclusions

Introduction

Section snippets

Methods

Results

Discussion

Drug Alcohol Depend

Frequency of nonfatal heroin overdosesurvey of heroin users recruited in nonclinical settings

BMJ

A 33-year follow-up of narcotics addicts

Arch Gen Psychiatry

Death and survival in a cohort of heroin addicts from London clinicsa 22-year follow-up study

Addiction

Deathsfinal data for 2002

Natl Vital Stat Rep

Witnessing heroin-related overdosesthe experiences of young injectors in San Francisco

Addiction

Experience of nonfatal overdose among heroin users in Adelaide, Australiacircumstances and risk perceptions

Addiction

Prevalence and circumstances of opiate overdose among injection drug users in the Russian Federation

J Urban Health

Brief report
Response to Overdose Among Injection Drug Users