Law enforcement attitudes toward overdose prevention and response
Introduction
Poisoning is the leading cause of adult injury mortality in the United States (US; Centers for Disease Control and Prevention, 2012a), composed primarily of drug poisonings (overdoses). Nationally, there has been a more than five-fold increase in unintentional drug overdose deaths since 1970 (Centers for Disease Control and Prevention, 2011). Opioid pain relievers are the most commonly involved type of drug, responsible for over half of unintentional drug overdoses (Centers for Disease Control and Prevention, 2012b). Geographic distribution of prescription opioid-involved deaths suggests not only differences in epidemiology but also in availability and provision of emergency medical resources, access to which may determine the injury outcome. In particular, a tendency of prescription opioid overdoses to occur outside of metropolitan areas in small town and suburban locations places greater emphasis on local public safety professionals for responding to these health emergencies. Like all injuries, the majority of drug poisoning deaths is preventable and, if witnessed, overdoses can be effectively reversed. Recent attention has focused on how first responders, both emergency medical technicians (EMTs) and police, can prevent and respond to overdoses (Centers for Disease Control and Prevention, 2012b). Much of this focus has been on providing first responders, particularly EMTs (e.g., other than paramedics), with naloxone to reverse opioid induced overdose (Banta-Green et al., 2013, Office of National Drug Control Policy, 2011, Office of National Drug Control Policy, 2012). Police are often trained in provision of first aid and larger police departments may have EMTs on staff, suggesting capacity for overdose response activities (c.f., Quincy, Massachusetts Police Department as example). However, numerous studies have documented reticence on the part of substance using populations to call 911 in the event of an overdose emergency (Bohnert et al., 2011, Burris et al., 2004, Darke et al., 2000, Green et al., 2009, Pollini et al., 2006, Sherman et al., 2007, Tobin et al., 2005, Tracy et al., 2005) for fear of police involvement. Given that there are significant barriers to wider, community-based dispensation of naloxone, fear of police involvement exacerbates limited community naloxone availability. Furthermore, little data exist regarding law enforcement attitudes toward overdose prevention and response; none focus on prescription opioid overdose prevention and response. Such data may shed light on the perceived role of police and may challenge the belief held by some that police are uninterested in supporting or becoming involved in overdose prevention and response efforts.
The public's perception of law enforcement as being uninterested in overdose prevention may be traced to over forty years of drug market enforcement practices and related criminal sentencing policies targeting urban (open) illicit drug markets, especially within communities of color (see Kerr et al., 2005). Research to date has consistently demonstrated that drug market enforcement practices are a critical structural determinant, either enhancing or minimizing drug-related morbidity and mortality (Beletsky et al., 2005, Bohnert et al., 2011, Cooper et al., 2012, Friedman et al., 2006, Friedman et al., 2011, Rhodes, 2002, Rhodes et al., 2006, Silverman et al., 2012). These enforcement practices have been shaped by guiding policing strategies, e.g., community or problem-oriented policing, COMPSTAT, “Stop and Frisk,” etc., (Geller and Fagan, 2010, Goldstein, 1979, McDonald, 2001, Weisburd et al., 2003, Willis et al., 2004), organizational characteristics (Chappell et al., 2006) and discretion (Walker, 1993), all of which vary by jurisdictional and political confluences. With some exception (Rivers et al., 2012), traditional street-level enforcement strategies remain the standard response toward illicit drug use (Kerr et al., 2005) irrespective of secondary harms, including an expansive correctional population, disparities in arrest rates for people of color, and felony disenfranchisement, to name a few. Research clearly demonstrates these practices create a marked climate of distrust, fear, secrecy, and uncertainty for drug users (Beletsky et al., 2005, Burris et al., 2004, Compton and Volkow, 2006). Exclusive drug market enforcement policing activity may contribute to higher drug overdose mortality rates through: (1) fear of police arrest among individuals who witness an overdose, thereby delaying the response of emergency personnel; (2) heightened police presence, thereby indirectly promoting drug use in seclusion; and (3) areas with more arrests having more incarcerations, wherein the post-release period is a known risk period for fatal overdose (Binswanger et al., 2007, Bohnert et al., 2011).
In contrast, a number of recent legal and policy changes explicitly include law enforcement partners and suggest there may be other opportunities for a community response that could reduce overdose mortality. First, the Office of National Drug Control Policy called for expanding the availability of naloxone (an opioid overdose antidote) beyond the public health arena to include first responders – especially law enforcement – and for dismantling legal barriers disallowing such practices to date (Kerilowske, 2012). Second, the National Association for Drug Diversion Investigators issued a public statement calling for law enforcement agencies to adopt policies allowing officers to carry and administer naloxone to individuals experiencing opioid overdose proclaiming, “the availability of this product will ultimately save many lives, as police officers are oftentimes the first responders where delays of only a few seconds can mean the difference between life and death” (National Association of Drug Diversion Investigators, 2012). Third, legal interventions via Good Samaritan Laws, which provide limited immunity from drug-related charges when 9-1-1 is called in an overdose emergency, and statutes allowing for “third party prescription” have served to lessen overdose secrecy, silence, and stigma (Beletsky et al., 2007, Compton and Volkow, 2006) and increase naloxone's availability and use (Davis and Chang, 2012). Moreover, current federal legislation, such as Stop Overdose Stat Act, would facilitate: (1) widening the purchase and distribution of naloxone; (2) educating physicians and pharmacists about overdose prevention and naloxone prescription; (3) training first responders, including law enforcement, on effective overdose response; and (4) implementation or enhancement of programs that provide overdose prevention, recognition, treatment, and response to individuals (National Association of Boards of Pharmacy, 2012).
The law enforcement community itself has a varied range of attitudes and perceptions about those who use drugs and related treatment modalities and policies (see Beyer et al., 2002). This workplace variance stems from the fact that law enforcement routinely witnesses the inherent human complexities of drug use and the outcomes of current drug control mandates (Beletsky et al., 2005). As such, novel drug control policies and practices (see Beletsky et al., 2011, Beletsky et al., 2005, Beyer et al., 2002, Rhodes et al., 2006, Rivers et al., 2012, Silverman et al., 2012) and, as previously outlined, recent legal and policy changes to standard drug control practices, may increase the odds of aligning public health and criminal justice objectives. As strategic policing innovations introduced over the past forty years such as community policing, “broken windows” policing, third party policing, hot spots policing, and evidenced based policing (Braga and Weisburd, 2007, Moore et al., 1997) suggest, policing has gradually shifted from an exclusive enforcement model to one more accepting of a problem-solving framework when encountering people affected by homelessness, mental illness, drug-market driven violence, substance abuse, and cardiac episodes (Hawkins et al., 2007, Kennedy and Wong, 2012, Morabito et al., 2013, Newman et al., 2002, Rivers et al., 2012, Schaefer Morabito, 2010, Wood et al., 2011). Most encouraging have been recent albeit jurisdictionally limited strategic innovations melding traditional public health prevention programs for people who inject drugs (PWID) with policing (Beletsky et al., 2011, Davis and Beletsky, 2009, DeBeck et al., 2008, Silverman et al., 2012). While there has been a range of studies examining the role of drug enforcement attitudes and practices on the health of PWID (Beletsky et al., 2005, DeBeck et al., 2008, Jardine et al., 2012, Rhodes et al., 2006, Silverman et al., 2012, Small et al., 2012) there have been no studies to date of law enforcement attitudes about overdose prevention and response, especially within the context of non-medical prescription opioid use (NMPU). The aim of this analysis is to explore law enforcement perspectives on overdose prevention and response from a subset of interviews collected during a Rapid Assessment and Response study investigating prescription opioid overdose outbreaks in three New England communities (the RARx Study).
Section snippets
Methods
Data collection was conducted in three small town and suburban locations in Connecticut (CT) and Rhode Island (RI). The RARx Study aimed to better understand patterns of prescription opioid overdose in selected communities experiencing high overdose burden and to suggest targeted ways to better prevent them. Study methods are reported elsewhere (Green et al., 2013). Briefly, field staff conducted qualitative interviews between June and August 2011, using a semi-structured interview guide.
Results
We collected 143 key informant interviews across the two states and three study sites; 13 interviews were conducted with law enforcement officials. The majority of all interviewees identified as White (90.8%) and not Hispanic (95%), and two-thirds were male. Law enforcement interviews from the study locations represented a range of experience: police chiefs or senior department officials (n = 3), detectives (n = 3), narcotics investigators (n = 2), community policing officers (n = 2), and patrol
Discussion
Our data suggest law enforcement officers are empathetic to the health problem of overdose. However, some officers may feel conflicted about their role in protecting public safety through enforcement of laws aimed to reduce the supply of drugs in communities. Views on law enforcement preventing overdose fatalities were complex but generally fit within activities associated with the concepts of community policing and good police relations. Importantly, respondents in our study sample indicated a
Role of funding source
This work was supported by a grant from the Centers for Disease Control and Prevention (CDC) (R21CE001846 Green (PI)). The funding source had no role in the study design, analysis, interpretation of the data, or decision to publish.
Contributors
TCG conceived of the study, oversaw data collection and analysis, and prepared the final manuscript. MR and SB helped collect the interview data, coded and analyzed the transcripts, and contributed to the first drafts of the manuscript. WP, NZ, RH and PC took part in the analysis and manuscript writing. TCG had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Conflict of interest
The authors report no conflicts of interest.
Acknowledgements
We gratefully acknowledge Roza Tammer, Rehan Ansari, and Nicole Pflug for their assistance in data collection and Corey Davis for his review of an earlier manuscript draft. We are also grateful to our three study communities for their involvement in the RARx Study.
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