Why are some people who have received overdose education and naloxone reticent to call Emergency Medical Services in the event of overdose?

Abstract

Background Overdose Education and Naloxone Distribution (OEND) training for persons who inject drugs (PWID) underlines the importance of summoning emergency medical services (EMS). To encourage PWID to do so, Colorado enacted a Good Samaritan law providing limited immunity from prosecution for possession of a controlled substance and/or drug paraphernalia to the overdose victim and the witnesses who in good faith provide emergency assistance. This paper examines the law’s influence by describing OEND trained PWIDs’ experience reversing overdoses and their decision about calling for EMS support. Methods Findings from two complementary studies, a qualitative study based on semi-structured interviews with OEND trained PWID who had reversed one or more overdoses, and an on-going fieldwork-based project examining PWIDs’ self-identified health concerns were triangulated to describe and explain participants’ decision to call for EMS. Results In most overdose reversals described, no EMS call was made. Participants reported several reasons for not doing so. Most frequent was the fear that despite the Good Samaritan law, a police response would result in arrest of the victim and/or witness for outstanding warrants, or sentence violations. Fears were based on individual and collective experience, and reinforced by the city of Denver’s aggressive approach to managing homelessness through increased enforcement of misdemeanors and the imposition of more recent ordinances, including a camping ban, to control space. The city’s homeless crisis was reflected as well in the concern expressed by housed PWID that an EMS intervention would jeopardize their public housing. Conclusion Results suggest that the immunity provided by the Good Samaritan law does not address PWIDs’ fear that their current legal status as well as the victim’s will result in arrest and incarceration. As currently conceived, the Good Samaritan law does not provide immunity for PWIDs’ already enmeshed in the criminal justice system, or PWID fearful of losing their housing.

“Once I’d done it once it was like writing your name”: Lived experience of take-home naloxone administration by people who inject drugs

“…'can I do this?'). Feedback from those involved in other THN programmes has also reported that naloxone was "easy" to administer or that PWID felt "comfortable" when using it (Lankenau et al, 2013;Banjo et al, 2014) often without the need for additional medical support (Koester et al, 2017). In this study, role adequacy varied between individuals and insecurities were evident owing to lack of experience, preparation, and confidence in themselves and in naloxone itself.…”

“…These approvals were a source of honour for the individuals involved, reinforcing and strengthening their role as helpers in their communities. Policies such as the 'Good Samaritan Law' in the USA have been created to encourage PWID to call the emergency services without fear of prosecution, yet many still have underlying fear and mistrust of emergency service personnel owing to negative experiences which prevents them from doing so (Koester et al, 2017). Examples of positive…”

“…Far fewer studies have been conducted that have focussed more on PWID's views and experiences of administering THN and the impact this has on them. To date, those which have been published mainly originate from North America (Worthington et al, 2006;Shermann et al 2008Shermann et al , 2009Wagner et al, 2014;Lankenau et al, 2014;Koester et al, 2017;Heavey, 2018), and one from China (Bartlett et al, 2011). Collectively, these studies provide valuable early insights into the barriers and enablers to participating in THN programmes, but also to the attitudes of the individuals involved and the effects naloxone can have on them and their relationships with their peers.…”

Stigma as a fundamental hindrance to the United States opioid overdose crisis response

“…Specific challenges include anticipated stigma [89], concerns about moral hazard [90][91][92], or ignorance about state legislation related to naloxone prescribing or dispensing [93,94]. Most states have passed "Good Samaritan laws" to limit criminal liability for bystanders who provide or summon aid when witnessing an overdose incident [95], but the streetlevel effectiveness of such legislation may be limited by anemic implementation and punitive signaling by criminal law and law enforcement, including high-profile "drug-induced homicide" prosecutions, loss of housing, and other legal repercussions [96,97].…”

Preventing opioid overdose with peer-administered naloxone: findings from a rural state

“…However, challenges remain with giving first responders, including law enforcement, the responsibility of overdose reversal. One significant barrier is that people who use drugs are often hesitant to call emergency services when an overdose occurs due to fear of police involvement [14,15]. First responders also report suffering emotional consequences due to increased numbers of overdose situations [16].…”