Elsevier

Drug and Alcohol Dependence

Volume 192, 1 November 2018, Pages 362-370
Drug and Alcohol Dependence

Full length article
“Feeling confident and equipped”: Evaluating the acceptability and efficacy of an overdose response and naloxone administration intervention to service industry employees in New York City

https://doi.org/10.1016/j.drugalcdep.2018.08.001Get rights and content

Highlights

  • The overdose response and naloxone module demonstrated efficacy and acceptability.

  • The module improves service industry employees’ opioid overdose-related knowledge.

  • Participants demonstrated more positive opioid overdose-related attitudes.

  • Future research should expand this intervention to a larger sample size.

Abstract

Background

The problem of injection drug use in public bathrooms has been documented from the perspectives of people who inject drugs and service industry employees (SIEs). Previous studies suggest that SIEs are unaware of how to respond to opioid overdoses, yet there are no behavioral interventions designed for SIEs to address their specific needs. In response to this gap in the field, we constructed, implemented, and evaluated a three-module behavioral intervention for SIEs grounded in the Information-Motivation-Behavioral skills model. This paper focuses on the evaluation of one module, namely, the intervention component addressing overdose response and naloxone administration (ORNA).

Methods

Participants were SIEs (N = 18 from two separate business establishments) recruited using convenience sampling. The study utilized a pre-/post-test concurrent nested mixed method design and collected quantitative and qualitative data including an evaluation of the intervention module. The primary outcomes were opioid overdose-related knowledge and attitudes. Acceptability was also assessed.

Results

SIEs demonstrated significant improvements (p <  0.01, Cohen’s d = 1.45) in opioid overdose-related knowledge as well as more positive opioid overdose-related attitudes (p< 0.01, Cohen’s d = 2.45) following the intervention. Participants also reported high levels of acceptability of the module and suggestions for improvement (i.e., more role-playing).

Conclusions

This study highlights the acceptability and evidence of efficacy of the ORNA module, as well as the utility of training SIEs in ORNA. The expansion of this training to other SIEs and public employees (librarians, etc.) who manage public bathrooms warrants further investigation.

Introduction

Drug overdose mortality rates per year in the United States (US) nearly tripled between 1999–2014 with opioids involved in almost two-thirds of fatalities (Rudd et al., 2016). In 2016, over 60,000 drug overdose fatalities were reported throughout the US (Centers for Disease Control and Prevention, 2017). New York City (NYC) experienced 1,374 drug overdose deaths in 2016 with 82% involving an opioid, with heroin being the most prevalent opioid involved (55%) and 44% involving fentanyl (New York City Department of Health and Mental Hygiene, 2017).

Reports suggest that public bathrooms,1 such as those in fast-food restaurants, coffee shops, parks, and libraries, are among the most commonly used public injecting locations reported by people who inject drugs (PWID) in NYC (Injection Drug Users Health Alliance, 2015; New York City Department of Health and Mental Hygiene, 2010, 2013). Subsequently, numerous overdoses and overdose deaths have occurred in public bathrooms throughout NYC and the US (Associated Press, 2016a,b; Keilman, 2018; Raymond, 2017; VanGilder, 2017).

A previous study conducted by our team focused specifically on business managers’ encounters with drug use in NYC and revealed that many (58%) had encountered drug use in their business’s public bathroom (herein referred to as ‘business bathrooms’) within the past 6-months and that approximately a third (34%) of them had also encountered improperly disposed syringes (Wolfson-Stofko et al., 2017). Additionally, almost all (90%) had no training in overdose response and naloxone administration (ORNA), though a substantial minority (14%) had encountered someone who was unresponsive, presumably due to drug use, within the previous 6-months (Wolfson-Stofko et al., 2017). These findings suggest that business managers and staff (herein referred to collectively as a ‘service industry employee’ (SIE)) unwittingly become first-responders in the event of an opioid overdose and are not trained on how to respond to an overdose and administer naloxone. However, thirty-six states, including New York State, have amenable naloxone access and Good Samaritan laws that would permit ORNA training and naloxone distribution to SIEs (The Network for Public Health Law, 2017).

However, SIEs also face additional occupational risks associated with injection drug use occurring in their business bathrooms such as needlestick injuries and, in some cases, distressed PWID. Therefore, we designed an innovative intervention specifically for SIEs called Harm Reduction for Business Bathrooms (HRBB). This intervention included modules on 1) ORNA, 2) needlestick prevention and 3) strategies for de-escalating encounters with people who use drugs in their business bathrooms. Harm Reduction for Business Bathrooms was grounded in the Information-Motivation-Behavioral Skills (IMB) model (Fisher and Fisher, 1992; Fisher et al., 1996, 2009), where information, motivation, and behavioral skills interact synergistically to improve readiness to engage in the target behaviors. Specifically, HRBB was based on the assumptions that improving the behavioral skills necessary to prevent needlesticks and respond to opioid overdose, would thereby increase motivation and readiness to utilize ORNA skills in real-world settings. To our knowledge, no intervention has coupled needlestick prevention and de-escalation strategies with an ORNA intervention module specifically suited to the needs of SIEs who encounter drug use in their business bathrooms.

Additionally, no studies have evaluated the acceptability and evidence of efficacy (with respect to improving opioid overdose-related knowledge and attitudes, the intervention’s primary outcomes) of an ORNA intervention provided to SIEs whose businesses provide a bathroom for customers. This study sought to determine if the HRBB ORNA module was acceptable and efficacious in educating the target population on opioid overdose-related knowledge and improving opioid overdose management attitudes.

Section snippets

Methods

This study utilized a pre-/post-test concurrent nested mixed method trial design, and all activities were approved by the Institutional Review Board at National Development and Research Institutes, Inc. A Certificate of Confidentiality was obtained from the Department of Health and Human Services and written informed consent was obtained from each participant.

Demographic and background characteristics

A total of 18 participants (N = 18) enrolled in this study. Half identified as female with a mean age of 30 years (range = 22–38 years). Twelve identified as White, three as Asian, two as Latinx, and one as Black. Participants had worked in the service industry for an average of seven years (SD = 4.32 years, range = 1–10 years) and at their current location an average of two years (SD = 1.80 years, range = 1 month–5.5 years). Eleven had Bachelor’s degrees, three had Master’s degrees, one had an

Discussion

In the current research, we explored the evidence of efficacy and acceptability of an ORNA intervention module embedded in a larger three-module intervention program designed for SIEs. Participants found the intervention module acceptable, and many believed that it would be beneficial for other SIEs and their colleagues to be trained in ORNA as a part of company policy. Results from this study provide further evidence supporting the expansion of ORNA to a wider variety of individuals and

Conclusion

This small study is the first to suggest evidence of efficacy in the training of SIEs in ORNA and that this module of the SIE-specific intervention is acceptable. The results from both the quantitative and qualitative components further support previous research that suggests that non-medical professionals are capable of identifying and managing opioid overdoses after a brief training.

Contributors

BWS conceptualized the project, designed the intervention, led recruitment, conducted the intervention, analyzed the quantitative and qualitative data, and took the lead in writing the manuscript. MVG assisted with project conceptualization, intervention development and manuscript preparation. LE assisted with intervention development, qualitative analysis and manuscript preparation. ASB assisted with intervention development, quantitative analysis and manuscript preparation. RC assisted with

Role of funding source

This study was supported by the National Institutes of Health (T32DA007233, P30DA011041, F7610-11, R01DA03675402). The funder had no involvement in the design, implementation or interpretation of study results.

Conflict of interest

The authors of this paper declare no conflict of interest. The opinions of the authors do not necessarily reflect those of National Institutes of Health, National Institute on Drug Abuse, National Development and Research Institutes, Inc., New York University, or City University of New York.

Acknowledgements

The authors would like to thank all of the SIE who participated in this training. We would also like to thank the Center for Drug Use and HIV Research (CDUHR), all of the BST fellows for their constructive discussions and support as well as Dr. Charles M. Cleland for his statistical assistance.

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