Training law enforcement to respond to opioid overdose with naloxone: Impact on knowledge, attitudes, and interactions with community members

Highlights

• Law enforcement officers are being trained to respond to opioid overdoses with naloxone.

• Brief trainings can improve competency and confidence in overdose response.

• Improved community relations could impact willingness to call 911 for overdose victims.

Abstract

Background

Training law enforcement officers (LEOs) to administer naloxone to opioid overdose victims is increasingly part of comprehensive efforts to reduce opioid overdose deaths. Such efforts could yield positive interactions between LEOs and community members and might ultimately help lower overdose death rates.

Methods

We evaluated a pilot LEO naloxone program by (1) assessing opioid overdose knowledge and attitudes (competency in responding, concerns about naloxone administration, and attitudes towards overdose victims) before and after a 30 min training on overdose and naloxone administration, and (2) conducting qualitative interviews with LEOs who used naloxone to respond to overdose emergencies after the training.

Results

Eighty-one LEOs provided pre- and post-training data. Nearly all (89%) had responded to an overdose while serving as an LEO. Statistically significant increases were observed in nearly all items measuring opioid overdose knowledge (p’s = 0.04 to <0.0001). Opioid overdose competencies (p < 0.001) and concerns about naloxone administration (p < 0.001) significantly improved after the training, while there was no change in attitudes towards overdose victims (p = 0.90). LEOs administered naloxone 11 times; nine victims survived and three of the nine surviving victims made at least one visit to substance abuse treatment as a result of a LEO-provided referral. Qualitative data suggest that LEOs had generally positive experiences when they employed the skills from the training.

Conclusions

Training LEOs in naloxone administration can increase knowledge and confidence in managing opioid overdose emergencies. Perhaps most importantly, training LEOs to respond to opioid overdose emergencies may have positive effects for LEOs and overdose victims.

Introduction

Since the mid-1990s, communities have responded to opioid-related overdose deaths by training laypeople to recognize and respond to witnessed overdoses using naloxone, an opioid antagonist that reverses the respiratory depressive effects of opioids. The number of programs in the US increased from 188 in 2010 to 644 in 2014 (Centers for Disease Control and Prevention, 2012, Wheeler et al., 2015). More recently, attention has turned towards increasing the capacity of uniformed first responders to respond to opioid overdose emergencies by equipping law enforcement officers (LEOs) with naloxone. Enlisting LEOs in the fight against opioid overdose deaths has been part of the US Office for National Drug Control Policy’s (ONDCP) National Drug Control Strategy since 2010 (ONDCP, 2010), and has been endorsed by other high-level officials and agencies (Office of the Attorney General, 2014, U.S. Department of Health and Human Services, 2015, World Health Organization Management of Substance Abuse Team, 2014). As of January, 2016, there were over 669 law enforcement agencies in 31 states known to be carrying naloxone (North Carolina Harm Reduction Coalition, 2015)

The rationale for LEO naloxone programs is twofold. First, in some communities LEOs may be the first on scene in advance of emergency medical services (EMS), particularly in rural areas where travel distances are great. In these areas, having an officer arrive on scene with naloxone may result in the overdose victim receiving a life-saving dose of the medication several minutes sooner than would have previously been possible (Davis et al., 2015). Second, in line with efforts to “harmonize” policing and public health practices (Beletsky et al., 2011, Beletsky et al., 2008, Silverman et al., 2012), enlisting LEOs to provide this life-saving and low-risk intervention may have beneficial effects on law enforcement-community relations (Davis et al., 2014).

Naloxone administration by LEOs in the US has been enabled by a series of state-level legislative changes that empower law enforcement officers to administer naloxone via a standing order or similar arrangement (Davis et al., 2015). As of September 2015, there were 42 states that had passed laws expanding naloxone, many of which explicitly empower law enforcement officers to administer the medication (Network for Public Health Law, 2015). In addition, 35 states have passed 911 Good Samaritan laws to encourage bystanders to summon aid in the event of an overdose (Network for Public Health Law, 2015). California Assembly Bill (AB) 635 (enacted 2013) and State Bill (SB) 1438 (enacted 2014) provided authorization for physicians to write standing order prescriptions under which non-medical personnel, including LEOs, can administer, train, and dispense naloxone. Consistent with other state laws (Davis et al., 2015), AB 635 also provided immunity from professional, civil, and criminal liability for individuals who administer naloxone in good faith to someone believed to be experiencing an overdose. California AB 472 (enacted 2013), known as a “911 Good Samaritan Law”, provided protection for individuals who call 911 in the event of an overdose against charges related to being under the influence or possession for personal use of drugs or drug paraphernalia.

Despite the growing popularity and rapid increase in law enforcement-based naloxone programs, the impact of these programs is still relatively understudied. To date there has been only one published study investigating whether LEO naloxone programs can reduce overdose death rates, which found that the deployment of a police officer-based naloxone program in Lorain County, Ohio corresponded with a decrease in opioid overdose deaths in the first nine months following program implementation (Rando et al., 2015). However, that study did not control for other confounding factors that could have had an effect on overdose deaths (e.g., community-based naloxone distribution, or changes in opioid prescribing practices, drug treatment availability, or drug market trends, etc.). A series of four case reports from North Carolina also demonstrate the feasibility of training law enforcement officers in overdose response (Kitch and Portela, 2016).

A study in three New England communities identified complex and sometimes conflicting opinions about the role of LEOs in preventing opioid overdose (Green et al., 2013). While the majority of LEOs in that study identified opioid overdose as a medical emergency and expressed some desire to help, there were also feelings of futility and helplessness in the face of the overwhelming fight against addiction and drug-related death (not unlike those expressed by laypeople who have experienced the loss of loved ones to drug overdose; Wagner et al., 2014). Research in Indiana revealed generally favorable attitudes among police officers towards incorporating naloxone administration into their role (Ray et al., 2015). These studies also found that LEOs generally feel that their first priority at the scene of an overdose is to protect medical personnel, rather than enforce drug laws (Green et al., 2013, Ray et al., 2015). These findings support the idea that training LEOs to respond to overdose including through the administration of naloxone is feasible and can be consistent with LEO priorities. However, researchers have also identified some ambivalence surrounding the multiple competing priorities for LEOs that may deter them from taking on the responsibility of responding to opioid overdoses using naloxone (Green et al., 2013).

In contrast, research among people who use drugs has shown that laypeople often hesitate to call 911 in the event of a drug overdose due to a fear of police response (Bohnert et al., 2011, Davidson et al., 2002, Tobin et al., 2005). For example, a large study of people who inject drugs (PWIDs) in Baltimore, Maryland found that only 63% of PWIDs called 911 for an overdose, and 52% of those who called delayed that call by more than five minutes (Pollini et al., 2006a). Among those who did not call 911 at all, more than two-thirds cited a law enforcement-related fear as their most important reason for not calling. This fear is not unfounded, as many studies have shown that people who use drugs experience arrests or police harassment at the scene of an overdose (Davidson et al., 2002, Enteen et al., 2010, Wagner et al., 2010). Being arrested on drug possession charges has also been associated with an elevated odds of experiencing a recent opioid overdose in cross-sectional research (Wagner et al., 2015).

Taken together, these bodies of research suggest that there is room for improvement in the area of community-LEO relations during opioid overdose emergencies. Responding to these emergencies as medical priorities may present an opportunity for LEOs to take on a different role at the scene and thereby mitigate some of the fear of calling 911 expressed by bystanders. The current investigation sought to add to the current knowledge base in two ways: (1) by assessing the impact of the training on attitudes and knowledge regarding opioid overdose and naloxone administration through pre- and post-training surveys, and (2) by describing the impact that the training had on actual policing experience through in-depth qualitative interviews with LEOs who responded to an opioid overdose emergency using naloxone following the training.