Training to reduce emergency responders' perceived overdose risk from contact with fentanyl: early evidence of success

Addressing Fear of Negative Consequences of Overdose Response: A Qualitative Study of the Perceptions of Service Industry Workers Who Encounter an Opioid Overdose in an Urban Commercial District in Atlanta, Georgia

BACKGROUND

The increased contamination of illicit drugs with fentanyl in the United States drug market has contributed to escalating mortality from drug overdose. Leisure and hospitality service industry workers are encountering opioid-triggered overdoses in their workplaces, such as restaurants and bars. Consequently, this increases the need for overdose education and naloxone distribution (OEND) training, which has been limited. We aimed to describe the experiences among service industry workers encountering an overdose in their workplace.

METHODS

We conducted in-depth qualitative interviews with service industry workers in Little Five Points (L5P), Atlanta, between October 2019 and April 2020 and triangulated methods with participant observations and fieldwork. Purposive criterion sampling methods were applied to recruit from different establishments in the L5P commercial district, which comprised restaurants, bars, retail shops, and theaters. After an initial seed sample was identified by engaging key stakeholders during fieldwork (business owners, managers, and the business association), a snowball sample followed for a final sample of N = 15. To contextualize the local population of harm reduction workers, people who use drugs and/or obtain safer drug consumption supplies in L5P (sterile syringes, safer using kits, naloxone), and service industry workers and their customers in L5P, the first author volunteered with an Atlanta syringe services program from October 2019 to April 2020. The first author conducted participant observations during the syringe exchange program and field notes were taken during observation (44 hours). This engagement ensured a rich, thick description. We used a pragmatic approach to thematic data analysis for this study. Data were analyzed iteratively and inductively from interviews and observations. Two independent researchers reviewed transcripts to identify passages in the data related to the question of interest. The passages were contextualized within the full data set independently to understand the relationships in developing a theory of what was commonly occurring across participants' experiences, and these relationships led to emerging salient themes regarding encountering an opioid overdose at work.

RESULTS

One salient theme related to overdose response emerged with the service industry workers included fear of negative consequences of overdose response, specifically, fear of disease transmission from artifacts of drug use and overdose response, including the spread of blood-borne disease, violence, and exposure to unintentional overdose. When discussing drug use, participants' beliefs about the potential for personal danger from drug use artifacts (syringes and discarded drugs) and violence were identified as barriers to opioid overdose responses.

CONCLUSIONS/IMPLICATIONS FOR OCCUPATIONAL HEALTH PRACTICE

Our findings provide valuable insights for tailoring OEND training for service industry workers to confront fears associated with opioid overdose response in their places of work to decrease mortality from the opioid epidemic. Harm reduction approaches need to be sensitive to the places in which overdose occurs and who the overdose responder is likely to be, which requires appropriately tailoring OEND training for service industry workers.

'It's the same thing as giving them CPR training': rural first responders' perspectives on naloxone

The Substance Abuse and Mental Health Services Administration's (SAMHSA) Harm Reduction grant program expanded access to several harm reduction strategies to mitigate opioid overdose fatalities, including expanding access to naloxone. Interviews with first responders in a frontier and remote (FAR) state were conducted to understand their job responsibilities in relation to overdose response and prevention and their perceptions of training laypersons to administer naloxone. This study includes 22 interviews with law enforcement, EMS and/or fire personnel, and members of harm reduction-focused community organizations. The study finds widespread support for increasing access to naloxone and training laypersons in naloxone administration throughout Montana, due to rural first responders' inability to meet the needs of residents and an overall lack of resources to address addiction and the effects of fentanyl. Participants from harm reduction-focused community organizations convey support for training lay persons, but also illuminate that real and perceived cultural opposition to harm reduction strategies could reduce the likelihood that laypeople enroll in naloxone training. This study adds to the literature because it focuses on first responders in a FAR area that would benefit from layperson naloxone education and administration training due to its geographic expansiveness and the area's overall lack of access to medications for opioid use disorder or other treatment services. Expanding harm reduction approaches, like increasing access and training laypersons to administer naloxone, might be FAR residents' best chance for surviving an opioid overdose.

Accidental Occupational Exposure to a Large Volume of Liquid Fentanyl on a Compromised Skin Barrier with No Resultant Effect

The high prevalence of fentanyl in the illicit drug supply has generated concern among first responders regarding occupational exposure. Social media sharing of unconfirmed first responder overdoses after brief exposure to fentanyl may be contributing to an inappropriate risk perception of brief dermal fentanyl exposure. This case details a dermal exposure to a large dose of analytically confirmed pharmaceutical fentanyl (fentanyl citrate, 10 microgram fentanyl base per ml), over a large skin surface area. Additionally, the exposure occurred at a site with some skin barrier compromise, a factor that can increase fentanyl absorption. The patient underwent appropriate decontamination and underwent a brief medical assessment with no clinical effects of opioid exposure observed. This information is of value to first responders and other health care workers who are at risk of occupational fentanyl exposure. Findings are consistent with in vitro and ex vivo data supporting low risk of rapid absorption after brief dermal fentanyl exposure.

Impact of SHIELD Police Training on Knowledge of Syringe Possession Laws and Related Arrests in Tijuana, Mexico

Between 2015 and 2018, we provided training for 1806 municipal police officers in Tijuana, Mexico, in an effort to improve their knowledge and behaviors related to HIV and injection drug use. Correct knowledge of syringe possession laws improved from 56% before training to 94% after training and was sustained at 24 months (75%). Knowledge improvement was associated with decreases in arrests for syringe possession over time (adjusted odds ratio [AOR] = 0.87; 95% confidence interval [CI] = 0.85, 0.90). Officers with correct knowledge had significantly lower odds of reporting arrests (AOR = 0.63; 95% CI = 0.44, 0.89). Training was associated with sustained improvements in knowledge and practices that advance public health. (Am J Public Health. 2022;112(6):860-864. https://doi.org/10.2105/AJPH.2021.306702).

Endogenous opiates and behavior: 2020

This paper is the forty-third consecutive installment of the annual anthological review of research concerning the endogenous opioid system, summarizing articles published during 2020 that studied the behavioral effects of molecular, pharmacological and genetic manipulation of opioid peptides and receptors as well as effects of opioid/opiate agonists and antagonists. The review is subdivided into the following specific topics: molecular-biochemical effects and neurochemical localization studies of endogenous opioids and their receptors (1), the roles of these opioid peptides and receptors in pain and analgesia in animals (2) and humans (3), opioid-sensitive and opioid-insensitive effects of nonopioid analgesics (4), opioid peptide and receptor involvement in tolerance and dependence (5), stress and social status (6), learning and memory (7), eating and drinking (8), drug abuse and alcohol (9), sexual activity and hormones, pregnancy, development and endocrinology (10), mental illness and mood (11), seizures and neurologic disorders (12), electrical-related activity and neurophysiology (13), general activity and locomotion (14), gastrointestinal, renal and hepatic functions (15), cardiovascular responses (16), respiration and thermoregulation (17), and immunological responses (18).

The Role of Misinformation and Stigma in Opioid Use Disorder Treatment Uptake

Background: Deaths due to opioid overdose continue to rise in the United States. Despite availability of effective treatment for opioid use disorder, uptake is low among those who misuse opioids. Methods: This paper explores the role of misconception, stigma, and misinformation in influencing decisions to initiate medications for opioid use disorder among patients and providers. Conclusion: Misinformation about opioids has been prevalent among future healthcare providers and first responders as well as pharmaceutical companies, which may have implications for treatment. Among individuals with opioid use disorder, treatment uptake and adherence have been negatively affected by misconceptions about treatment efficacy and side effects, as well as stigma. We discuss the role of social media, education, and the community, in mitigating misinformation and addressing misconceptions about opioids and treatment options.

Can touch this: training to correct police officer beliefs about overdose from incidental contact with fentanyl

Misinformation about overdose risk from accidentally inhaling or touching fentanyl is widespread among police in the United States. This may aggravate already elevated burdens of officer stress and burnout, while chilling lifesaving overdose response. Police education has shown promise in reducing false beliefs about fentanyl. To better understand the potential of training interventions in correcting officer knowledge, we administered a 10-min online training with corrective messaging about occupational overdose risk from fentanyl contact to 204 police officers in Indiana. Overall, 129 officers (63%) completed baseline survey and 69 (34%) completed follow-up instrument. Using a 6-point Likert scale, we documented assent with the statement: "First responders who encounter fentanyl are at great risk of overdose by touching it or inhaling it." At baseline, 79.8% expressed agreement, while 20.2% disagreed. At follow-up, 39.1% agreed, while 60.9% disagreed (p < .001). Baseline responses varied in that those officers without a college degree and those on patrol were more likely to report false beliefs. A brief online training intervention holds promise for correcting false beliefs about the risk of fentanyl overdose under circumstances commonly encountered by police.

Perceived vulnerability to overdose-related arrests among people who use drugs in Maryland

BACKGROUND

People who use drugs (PWUD) must weigh complex legal scenarios when seeking help during overdose events. Good Samaritan laws (GSL) offer limited immunity for certain low-level drug crimes to encourage PWUD to call 911. Drug-induced homicide laws (DHL) allow for criminal prosecution of people delivering drugs that result in overdose death and may exert opposing effects on the decision-making process. We examined whether perceptions of these laws were related to overall perceived vulnerability to overdose-related arrests, which can impact help-seeking and overdose mortality.

METHODS

We conducted a cross-sectional study of PWUD (N = 173) in Anne Arundel County, Maryland and measured sociodemographic characteristics, structural vulnerabilities, and knowledge of GSL and DHL. Perceived vulnerability to overdose-related arrest was defined as self-reported concern arising from calling 911, receiving medical help, or supplying drugs in the event of an overdose. Multivariable logistic regression was used to identify significant correlates of perceived vulnerability to overdose-related arrest.

RESULTS

Most participants were aware of DHL (87%) and half were aware of GSL (53%). Forty-seven percent of PWUD expressed concern about arrest during or due to an overdose. After adjustment, positive correlates of perceived vulnerability to arrest were non-white race (aOR 2.0, 95% CI 1.5-2.5) and hearing of somebody charged with DHL (aOR 3.1, 95%CI 1.9-5.0), and negative correlates were history of drug treatment (aOR 0.6, 95%CI 0.4-1.0), receiving naloxone (aOR 0.6, 95% CI 0.4-1.0), and having made, sold or traded drugs in the past 3 months (aOR 0.4, 95% CI 0.2-0.9).

CONCLUSIONS

We report persisting concern about arrest during overdose events among street-based PWUD facing a complicated landscape of legal protections and liabilities. Findings demonstrate clear racial disparities of concern outside an urban centre, where impacts of policing on health are less studied, and present evidence that DHL may compromise overdose prevention efforts. Changes to drug policy and enforcement including police nonattendance at overdose scenes may be necessary to promote help-seeking among PWUD and reduce overdose fatalities.

Perceived occupational risk of fentanyl exposure among law enforcement

BACKGROUND

Although toxicologists, medical professionals, and service providers have determined that the risk of overdose from fentanyl exposure is extremely low for law enforcement and other first responders, hundreds of media and social media accounts contradict these facts, making these civil servants unnecessarily concerned about such occupational hazards.

METHODS

We conducted a qualitative study to explore knowledge and fear of fentanyl exposure by interviewing 23 law enforcement leaders and officers in five diverse law enforcement agencies in the United States.

RESULTS

Nearly all leaders and officers interviewed wrongly believed that dermal exposure to fentanyl was deadly and expressed fear about such exposure on scene. Officers had a lack of education about fentanyl exposure and faulty or dubious sources of information about it.

CONCLUSION

There is a substantial, pressing need for dissemination of research about the lack of overdose risk associated with dermal fentanyl exposure through channels that law enforcement trust, including through basic academy, in-service training, and law enforcement bulletins and newsletters.

Reducing police occupational needle stick injury risk following an interactive training: the SHIELD cohort study in Mexico

Objective

At a time of unprecedented attention to the public health impact of policing, it is imperative to understand the role of occupational safety in shaping officer behaviours. We assessed the longitudinal impact of police training in a quasi-experimental hybrid type-1 trial to reduce syringe-related occupational risk, while realigning police practices with public health prevention among people who inject drugs (PWID).

Setting

Tijuana, Mexico.

Participants

Of 1806 Tijuana municipal police trainees, 771 reporting previous exposure to syringes were randomly selected for follow-up. All participants completed at least one follow-up visit; attrition at 24 months was 8%.

Intervention

Between 2015 and 2016, officers received a training intervention (Safety and Health Integration in the Enforcement of Laws on Drugs, SHIELD) bundling occupational needle stick injury (NSI) prevention with health promotion among PWID.

Outcome measures

Longitudinal analysis with generalised linear mixed models to evaluate training impact on occupational NSI risk via NSI incidence and prevalidated Syringe Threat and Injury Correlates (STIC) score. This composite indicator integrates five self-reported risky syringe-handling practices (eg, syringe confiscation, breaking) and was used as a proxy for NSI risk due to reporting bias and concerns about reliability of NSI incidence reports.

Results

No change in self-reported NSI incidence was observed, but significant reductions in risk (16.2% decrease in STIC score) occurred at 3 months, with a sustained decrease of 17.8% through 24 months, compared with pretraining (p<0.001). Police assignment (patrol vs administration) moderated the training effect (p=0.01). Younger age, male gender, lower rank and previous NSI were independently and significantly associated with higher NSI risk overtime, although all groups demonstrated significant reductions post-training.

Conclusions

SHIELD is the first intervention to be associated with significant sustained changes in police practices that pose risk for both occupational and the public’s health. Integrating occupational safety and public health education should inform other interventions to mitigate the community health detriments of policing behaviours.

Trial registration number

NCT02444403.

Working near a supervised injection facility: A qualitative study of perspectives of firefighter-emergency medical responders

BACKGROUND

While firefighter-emergency medical responders (FF-EMR) are important stakeholders in cities considering the implementation of a supervised injection facility (SIF), there is little information on perspectives of first responders who serve these communities. The aim of the present study was to identify FF-EMR perspectives on working near a SIF.

METHODS

FF-EMRs from Vancouver Fire and Rescue Services completed an online survey that queried participant perspectives on working near a SIF.

RESULTS

Four main themes were identified: positive effects, negative effects, duration of assignment, and sense of duty. Similar percentages of first responders reported positive (22.2%) and negative aspects (25.9%) of working near the SIF, while some (18.5%) indicated preference for a short-term assignment to the SIF area. FF-EMRs most commonly described a sense of duty (35.2%).

CONCLUSIONS

To our knowledge, our study is the first to identify FF-EMR perspectives related to work near a SIF. Perspectives and concerns of first responders should be considered in policy debates about implementation of new SIFs to guarantee an adequately-prepared first responder workforce.