Pathways to racial disparities in the effects of Good Samaritan Laws: A mixed methods pilot study

Harm Reduction: The Neglected Pillar of US Drug Policy

Harm reduction programs provide tools that enable people who use drugs to do so more safely in a nonstigmatizing environment without the goal of them necessarily seeking treatment or abstinence. Most harm reduction programs in the United States distribute sterile syringes and naloxone and safely dispose of used syringes and other drug use supplies. Many also provide drug checking services, and other safer use supplies. These programs exist on a limited scale and often face restrictions on their funding and scope of operations. While research demonstrates the effectiveness of existing programs in preventing infectious disease transmission and fatal overdose, there is less evidence about conditions that support the effective expansion and sustainment of existing models. Other harm reduction interventions such as overdose prevention centers and safer supply programs have promising international evidence but are prohibited or severely restricted under US law. In this review, we summarize the evidence for harm reduction interventions, describe the policy environment in which they exist, and provide recommendations to better align drug policy with existing and emerging evidence in the US context.

How do restrictions on opioid prescribing, harm reduction, and treatment coverage policies relate to opioid overdose deaths in the United States in 2013-2020? An application of a new state opioid policy scale

BACKGROUND

Identifying the most effective state laws and provisions to reduce opioid overdose deaths remains critical.

METHODS

Using expert ratings of opioid laws, we developed annual state scores for three domains: opioid prescribing restrictions, harm reduction, and Medicaid treatment coverage. We modeled associations of state opioid policy domain scores with opioid-involved overdose death counts in 3133 counties, and among racial/ethnic subgroups in 1485 counties (2013-2020). We modeled a second set of domain scores based solely on experts' highest 20 ranked provisions to compare with the all-provisions model.

RESULTS

From 2013 to 2020, moving from non- to full enactment of harm reduction domain laws (i.e., 0 to 1 in domain score) was associated with reduced county-level relative risk (RR) of opioid overdose death in the subsequent year (adjusted RR = 0.84, 95 % credible interval (CrI): 0.77, 0.92). Moving from non- to full enactment of opioid prescribing restrictions and Medicaid treatment coverage domains was associated with higher overdose in 2013-2016 (aRR 1.69 (1.35, 2.11) and aRR 1.20 (1.11, 1.29) respectively); both shifted to the null in 2017-2020. Effect sizes and direction were similar across racial/ethnic groups. Results for experts' highest 20 ranked provisions did not differ from the all-provision model.

CONCLUSIONS

More robust state harm reduction policy scores were associated with reduced overdose risk, adjusting for other policy domains. Harmful associations with opioid prescribing restrictions in 2013-2016 may reflect early unintended consequences of these laws. Medicaid coverage domain findings did not align with experts' perceptions, though data limitations precluded inclusion of several highly ranked Medicaid policies.

Barriers to calling emergency services amongst people who use substances in the event of overdose: A scoping review

BACKGROUND

North America is grappling with an ongoing drug overdose crisis. While harm reduction measures like take-home naloxone kits, and supervised consumption sites, have helped reduce mortality, other strategies to address this public health emergency are required. Good Samaritan Laws (GSLs) offer legal protection for individuals who report overdoses, yet people who use substances (PWUS) may still hesitate to seek help due to concerns about existing legislation. This scoping review explores barriers preventing PWUS from calling emergency services for overdoses, along with potential solutions and facilitators to address this challenge.

METHODS

PRISMA-ScR was used as a guide to conduct this study. Health sciences librarians searched Medline, Embase, PsychINFO, CINAHL, and SCOPUS to identify relevant articles. Six reviewers contributed to screening and extracting the articles through Covidence. Two reviewers performed thematic analysis using NVivo software to identify key barriers and facilitators.

RESULTS

An initial search found 6275 articles for title and abstract screening, resulting in 48 studies meeting the inclusion criteria. The primary barrier to calling 911 pertained to concerns about police arrivng with other first responders, especially regarding their presence and involvement at the scene of overdose. This was followed by legal repercussions, including fear of arrest, incarceration, and fear of eviction, amongst others. Some studies noted the lack of knowledge or trust in GSLs as a deterrent to seeking medical assistance. Additional barriers included concerns about privacy and confidentiality, preference to manage an overdose alone/receive help from another peer, confidence in naloxone effectiveness, limited access to cell phones, peer pressure to not call for help, and identifying as Black, Indigenous, or a Person of Colour (BIPOC). Facilitators include increased GSL awareness among PWUS and law enforcement, expanded legal safeguards for 911 callers, reduced police intervention in overdose cases, and enhanced naloxone availability at key access points.

CONCLUSION

Despite the good intentions of GSLs, PWUS continue to experience significant barriers to calling emergency services in the event of an overdose. Understanding these barriers and key facilitators is necessary to inform future drug policy and advocacy efforts.