'You're not just a medical professional': Exploring paramedic experiences of overdose response within Vancouver's downtown eastside

Creating Opioid Response Specialists: A Harm Reduction Initiative

Aim: Each year, more than 100,000 Americans die from an overdose. Most of these deaths are attributed to high-potency opioids, including fentanyl. People who use drugs face multiple barriers to treatment including access, knowledge of options, and adverse medical experiences. In 2022, Worcester County, Massachusetts saw a sharp increase in overdose deaths. In response, our team, based in Central Massachusetts developed and implemented an Opioid Response Specialist (ORS) Program, under the auspices of a mobile addiction service which has been operating in our area since 2021.

Methods: The Mobile Addiction Service is composed of physicians and advanced practice providers to facilitate low-barrier access to medications for opioid use disorder (MOUD) and harm reduction resources and the ORS service includes two care givers with emergency medical services (EMS) experience, currently also working as paramedics in the area. A model curriculum for the ORS role was developed and then the pilot testing of this role within the existing mobile addiction service was performed. These specialists were trained to the paramedic level and added extensive experience with overdose reversal, phlebotomy, wound care, and additional touch points with high-risk patients to the mobile service.

Results: As a result, we saw increases in naloxone and clean syringe distribution, and hepatitis C and human immunodeficiency virus screening. The integration of these personnel within the mobile addiction service also facilitated the uptake of opioid use disorder treatment interventions by our city's EMS which resulted in further improvements to city-wide naloxone distribution and the use of buprenorphine/naloxone after overdose reversal.

Conclusions: Based on our initial work, the concept of an ORS, especially when embedded with a mobile addiction service, has the potential to improve access to harm reduction as well as form the basis of a training program to extend the skills and scope of personnel with a background in EMS practice.

Predictors of emergency medical transport refusal following opioid overdose in Washington, DC

BACKGROUND AND AIMS

Patient initiated transport refusal during Emergency Medical Service (EMS) opioid overdose encounters has become an endemic problem. This study aimed to quantify circumstantial and environmental factors which predict refusal of further care.

DESIGN

In this cross-sectional analysis, a case definition for opioid overdose was applied retrospectively to EMS encounters. Selected cases had sociodemographic and situational/incident variables extracted using patient information and free text searches of case narratives. 50 unique binary variables were used to build a logistic model.

SETTING

Prehospital EMS overdose encounters in Washington, DC, USA, from July 2017 to July 2023.

PARTICIPANTS

Of EMS encounters in the study timeframe, 14 587 cases were selected as opioid overdoses.

MEASUREMENTS

Predicted probability for covariates was the outcome variable. Model performance was assessed using Stratified K-Fold Cross-Validation and scored with positive predictive value, sensitivity and F1. Prediction accuracy and McFadden's pseudo-R squared are also determined.

FINDINGS

The model achieved a predictive accuracy of 78% with a high positive predictive value (0.83) and moderate sensitivity (0.68). Bystander type influenced the refusal outcome, with decreased refusal probability associated with family (nondescript) (-28%) and parents (-16%), while presence of a girlfriend increased it (+28%). Negative situational factors like noted physical trauma (-62%), poor weather (-14%) and lack of housing (-14%) decreased refusal probability. Characteristics of the emergency response team, like a prior crew member encounter (+20%) or crew experience <1 year (-36%), had a variable association with transport.

CONCLUSIONS

Refusal of emergency transport for opioid overdose cases in Washington, DC, USA, has expanded by 43.8% since 2017. Several social, environmental and systematic factors can predict this refusal. Logistic regression models can be used to quantify broad categories of behavior in surveillance medical research.

EMS Paramedics and Law Enforcement Officers' Experiences with Joint-Response Efforts on Suspected Opioid Overdose Calls: A Qualitative Study

In the United States, the opioid crisis remains a nationwide public health emergency. Narcan laws have increased medical collaboration between emergency medical services (EMS) paramedics and law enforcement officers (LEOs), yet research on joint opioid-response efforts with these first responders remains underexplored. Using a phenomenological approach, this study explores EMS paramedics and LEOs' experiences with joint-response efforts on suspected opioid overdose calls amidst the ongoing opioid crisis. Researchers conducted semi-structured interviews with 14 first responders (n = 8 EMS paramedics; n = 6 LEOs) from a large Central Florida emergency services district covering urban, suburban, and rural areas. Four major themes emerged: (1) facilitators to joint-response efforts; (2) barriers to joint-response efforts; (3) concerns for patient co-occurring behavioral health conditions; and (4) perceived solutions. Overall, participants described mutual respect, reliance, and communication as key facilitators, while barriers included conflicting on-scene priorities and differences in Narcan protocols. Concerns for co-occurring behavioral health (i.e., addiction and mental health) conditions among overdose patients included difficulties in assessing mental health and the availability of wraparound services, yet these concerns remained secondary to medical treatment during an opioid-related emergency. Key solutions included enhanced Narcan training for LEOs and increased availability of behavioral health services for long-term patient care. This research contributes to existing literature on opioid overdose response by specifically examining joint-response efforts between EMS paramedics and LEOs. These findings may be applicable to other partnering agencies such as mental health crisis teams and should be explored across behavioral health collaborations.

Longitudinal Assessment of Emergency Responders' Attitudes Toward People Who Overdose and Naloxone Following an Overdose Education Training

BACKGROUND

In addition to teaching overdose recognition and response, overdose education and naloxone distribution (OEND) trainings for emergency responders aim to improve trainee attitudes toward people who use drugs and toward naloxone. This study examines the training effectiveness long term, as well as the extent to which improvements are dependent on profession type or recent experience administering naloxone.

METHODS

A total of 774 emergency responders, consisting of law enforcement officers (LEOs) (n = 624, 81%) and emergency medical service (EMS) personnel (n = 150, 19%), attended OEND trainings and completed surveys immediately prior to ("pre") and following ("post") the training, as well as 6 months later ("follow-up"). Survey items assessed attitudes toward people who have overdosed, naloxone-related risk compensation (ie, "enabling") beliefs, and whether participants had administered naloxone since attending the training. Multiple regression and estimated marginal means were used to evaluate changes in scores.

RESULTS

Emergency responders showed improved attitudes (pre = 2.60, follow-up = 2.45, P < .001) and risk compensation beliefs (pre = 2.97, follow-up = 2.67, P < .001) 6 months following the training. Follow-up scores differed by profession, with LEOs endorsing worse attitudes (difference = 0.55, P = .013) and more risk compensation beliefs (difference = 0.67, P = .014) than EMS. In addition, having recently administered naloxone predicted more negative attitudes (EMS: difference = 0.55, P = .01; LEO: difference = 0.54, P = .004) and risk compensation beliefs (EMS = 0.73, P = .006; LEO = 0.69, P = .002) at follow-up.

CONCLUSION

Six months after an OEND training, emergency responders' attitudes toward people who overdose, and their risk compensation beliefs remained improved. However, LEOs had more negative follow-up attitudes and beliefs compared to EMS. Emergency responders who had administered naloxone had worse attitudes and beliefs at follow-up than those who had not. Of note, our sample evidenced sizable attrition between pre and follow-up assessments, leaving room for selection bias. Future studies should investigate how to mitigate negative effects of administering naloxone on attitudes toward those who overdose, and belief that naloxone is "enabling."

'We are expected to be problem solvers'-Paramedics' performance expectations through the lens of organizational socialization: An interview study

AIM

To explore Finnish paramedics' perceptions of work-related performance expectations in relation to work experience, and understand how organizational socialization contributes to understanding paramedics' performance expectations.

DESIGN

A qualitative design with a deductive-inductive approach utilizing a social constructivist framework. The organizational socialization framework by Wanberg was used as the theoretical basis.

METHODS

Data were collected between May and August 2023, using group and individual interviews of newly graduated (n = 9) and experienced paramedics (n = 13). Participants were recruited via social media channels. Data were first analyzed deductively, according to constructs of the organizational socialization framework (role clarity, task mastery, and social acceptance), then inductively, using codes not utilized in the deductive phase.

DATA SOURCES

Interviewed Finnish paramedics (N = 22), both newly graduated paramedics (n = 9) and experienced paramedics (n = 13). The interviews were performed remotely and then transcribed into text.

RESULTS

Our findings showed comparable performance expectations between newly graduated and experienced paramedics, mismatches in role clarity of paramedic work, challenges in both learning and upholding professional competence, and difficulties of social acceptance into the paramedic community. There were variations in how expectations were perceived between groups, indicating that experience might partly affect how paramedics identify and manage performance expectations. The organizational socialization framework enables the contextualization of these performance expectations.

CONCLUSIONS AND IMPLICATIONS

Paramedic work involves challenges to upholding clinical competence, aligning to a professional role, and social integration into the professional community. Our research contributes to understanding how paramedics perceive these challenges as performance expectations in different stages of their careers and how they could be managed utilizing a framework for organizational socialization. The socialization of paramedics into the workforce needs to account for these performance expectations, especially considering the changing paradigm of paramedic work, role, and societal expectations.

PATIENT OR PUBLIC CONTRIBUTION

No Patient or Public Contribution.

"It's Pretty Sad If You Get Used to It": A Qualitative Study of First Responder Experiences with Opioid Overdose Emergencies

BACKGROUND

First responders play a vital role in the United States opioid drug overdose crisis, a public health emergency that has claimed many lives.

OBJECTIVE

We sought to investigate first responders' experiences and attitudes toward opioid overdose emergencies and the ongoing crisis, as well as emotional effects, coping strategies, and support systems.

METHODS

A convenience sample of first responders (n = 18) at the Columbus Fire Division, with experience responding to opioid emergencies, participated in semi-structured telephone interviews between September 2018 and February 2019. Interviews were recorded, transcribed verbatim, and analyzed using content analysis for themes.

RESULTS

While almost all participants described overdose emergencies as routine, they recalled some as memorable and emotionally impactful. Almost all respondents were frustrated by the high rates of overdose among their patients and the lack of sustainable improvements in outcomes, yet expressed a strong moral commitment to caring for patients and saving lives. Themes of burnout, compassion fatigue, and hopelessness emerged, as did themes of increased compassion and empathy. Support for personnel experiencing emotional difficulty was either lacking or underutilized. Further, many felt public policies should prioritize more permanent resources and improve access to care, and believed that people who use drugs should face greater accountability.

CONCLUSION

First responders perceive a moral and professional duty to treat patients who overdose, despite their frustrations. They may benefit from additional occupational support to cope with the resultant emotional effects of their role in the crisis. Addressing macro-level factors contributing to the overdose crisis and improving patient outcomes could also positively affect first responder wellbeing.

"Another tool in the toolkit"-Perceptions, suggestions, and concerns of emergency service providers about the implementation of a supervised consumption site

BACKGROUND

As Supervised Consumption Sites (SCS) are implemented in the United States, it is important to consider the needs and perceptions of impacted stakeholders. Emergency service providers (ESP) have a central role in responding to the overdose epidemic. This study intended to assess the how ESP perceive the potential implementation of an SCS in their community, as well as solicit program design and implementation-related concerns and suggestions.

METHODS

In-depth interviews were conducted by videoconference with 22 ESP, including firefighters, paramedics, police, and social workers in King County, Washington, USA. Data were analyzed using a thematic analysis approach.

RESULTS

Participants expressed the importance of feeling safe while responding to calls where drug use is involved and highlighted how this perception would be linked to ESP response times to calls from an SCS. Suggestions for improving the perceived safety of an SCS included training program staff in de-escalation as well as planning the layout of the SCS to accommodate ESP. The inadequacy of the emergency department as a point of care for PWUD was also identified as a theme, and some participants expressed enthusiasm regarding the prospect of the SCS as an alternative destination for transport. Finally, support for the SCS model was conditional on the appropriate utilization of emergency services and a reduction in call volume. Participants listed clarifying roles and pursuing opportunities for collaboration as ways to ensure appropriate utilization and maintain positive working relationships.

CONCLUSION

This study builds on literature regarding stakeholder perceptions of SCS by focusing on the perceptions of a critically important stakeholder group. Results enhance understanding of what motivates ESP to support SCS implementation in their community. Other novel insights pertain to ESP thoughts about alternative care delivery models and strategies for emergency department visit diversion.

(Re)situating expertise in community-based overdose response: Insights from an ethnographic study of overdose prevention sites (OPS) in Vancouver, Canada

Overdose Prevention Sites (OPS) are low-barrier services where people may use illicit drugs under the monitoring of staff trained to provide life-saving care in the event of an overdose. In British Columbia (BC), Canada, OPS have been rapidly scaled-up as a community-based response to the overdose crisis and are staffed primarily by community members who are also people who use drugs (PWUD). While it is known that PWUD perform vital roles in OPS and other community-based overdose interventions, the expertise and expert knowledge of PWUD in this work remains under-theorised. This study draws on 20 months of ethnographic fieldwork in Vancouver, BC (July 2018 to March 2020), to explore how OPS responders who are PWUD developed and enacted expertise in overdose response. Ethnographic fieldwork focused on four OPS located in Vancouver's Downtown Eastside (DTES) and Downtown South neighbourhoods. Methods included 100 hours of observation in the sites and surrounding areas, three site-specific focus groups with OPS responders (n=20), and semi-structured interviews with OPS responders (n=14) and service users (n=23). Data was analysed with the aim of characterizing the knowledge underpinning responders' expertise, and the arrangements which allow for the formation and enactment of expertise. We found that OPS responders' expertise was grounded in experiential knowledge acquired through their positionality as PWUD and members of a broader community of activists engaged in mutual aid. Responders became skilled in overdose response through frequent practice and drew on their experiential and embodied knowledge of overdose to provide care that was both technically proficient and responsive to the broader needs of PWUD (e.g. protection from criminalization and stigmatizing treatment). Responders emphasized that the spatial arrangements of OPS supported the development of expertise by facilitating more specialized and comprehensive overdose care. OPS became sites of collective expertise around overdose management as responder teams developed shared understandings of overdose management, including processes for managing uncertainty, delegating team responsibilities, and sharing decision-making. This research re-situates theoretical understandings of expertise in community-based overdose response with implications for overdose prevention interventions. Findings underscore the experiential and embodied expertise of PWUD as community-based responders; the importance of supportive environments and team-based approaches for overdose response; and the benefits of community-driven training that extends beyond technical skills of overdose identification and naloxone administration.

Change in Police Attendance at Overdose Events following Implementation of a Police Non-Notification Policy in British Columbia

Introduction. Bystanders at overdose events often hesitate to call 911 due to fear of police involvement. To address this, in 2016, British Columbia Emergency Health Services (BCEHS) introduced a policy to not routinely inform police of overdose events. This study explores change in police attended overdose events after the policy was implemented. Methods. Data on police attended overdose events were derived from naloxone administration forms in BC’s Take-Home Naloxone (THN) kits returned before and after the policy change. Segmented regression was conducted to quantify change in police attended overdose events. Results. The average proportion of police attended overdose events pre-policy was 55.6% compared to 37.9% post-policy. The segmented regression model demonstrated a 0.98% (95% CI: (−1.70 to −0.26)) decline ( $p=0.01$ ) in police attended overdose events each month following the policy. Conclusion. Our findings suggest that the BCEHS policy contributed to a decrease in police attended overdose events.

First Responders' Views of Naloxone: Does Stigma Matter?

BACKGROUND

Prior work has suggested that first responders have mixed feelings about harm reduction strategies used to fight the opioid epidemic, such as the use of naloxone to reverse opioid overdose. Researchers have also noted that provider-based stigma of people who use opioids (PWUO) may influence perceptions of appropriate interventions for opioid use disorder (OUD). This study examined first responders' perceptions of naloxone and the relationship between stigma of OUD and perceptions of naloxone.

METHODS

A web-based survey assessing perceptions of PWUO and naloxone was administered to 282 police officers and students enrolled in EMT and paramedic training courses located in the Northeastern United States. Bivariate and multivariable analyses assessed the relationship between variants of stigma (e.g., perceived dangerousness, blame, social distance, and fatalism) and self-reported perceptions of naloxone.

RESULTS

Participants, in the aggregate, held slightly negative attitudes toward the use of naloxone. Findings from multivariable modeling suggest that stigma of OUD, living in a rural area, and prior experience administering naloxone, were significantly and inversely related to support for the use of naloxone. Support for the disease model of addiction and associating drug use with low socioeconomic status were positively related to support for the use of naloxone.

CONCLUSION

Efforts to alleviate perceptions of PWUO as dangerous, blameworthy, or incapable of recovery may increase first responders' support for naloxone. To this end, first responder training programs should include instruction on the disease model of addiction, and more broadly, attempt to foster familiarity between PWUO and the professionals who serve them.

Finnish paramedics' professional quality of life and associations with assignment experiences and defusing use - a cross-sectional study

Background

Paramedics experience traumatic events and social emergencies during assignments while also being subjected to verbal and physical threats. Consequently, they are at risk for burnout and secondary traumatic stress, factors inherent to professional quality of life. Defusing and peer-support potentially decrease such symptoms; however, perceived defusing needs and use are not always balanced. Our aim was to explore Finnish paramedics’ professional quality of life, using the Professional Quality of Life Scale, with associations to EMS assignment experiences as well as formal and informal defusing need and use over a 12-month period.

Methods

A quantitative study of 257 Finnish paramedics using a cross-sectional design. Study outcomes were secondary traumatic stress (STS), compassion satisfaction (CS), and burnout (BO) scores using the modified 9-item Short Professional Quality of Life scale (ProQOL). Likert-type scales were used to collect participants’ recollections of assignment experiences and defusing from a 12-month period. Associations were explored using Spearman’s correlation coefficients.

Results

Short ProQOL score medians were STS 4.00 (IQR 3), BO 6.00 (IQR 3) and CS 13.00 (IQR 3). STS and BO correlated to experiences of social emergencies and traumatic events while BO correlated to experiences of threat situations (r = 0.206, p = .001). Paramedics perceived a need for defusing in general associated with STS (r = 0.178, p < .001) and participated in informal defusing. Participation in defusing of any form did not associate with ProQOL scores.

Conclusions

Finnish paramedics’ more frequent experiences of social emergencies, traumatic events, and paramedic-directed threat situations were associated with higher levels of STS and BO. STS was also associated with paramedics’ increased need for defusing and use of informal peer defusing, although neither STS, BO or CS scores associated to any defusing form. Managing paramedics STS and BO, while fostering CS, could therefore be a future research focus.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-11851-0.

Police officers' knowledge, understanding and implementation of the Good Samaritan Drug Overdose Act in BC, Canada

INTRODUCTION

In May 2017, the Good Samaritan Drug Overdose Act (GSDOA) was enacted in Canada - amending the Controlled Drugs and Substances Act. For people present at an overdose, the GSDOA offers legal protection from simple drug possession as well as breach of charges related to simple possession including probation, pre-trial release, conditional sentences, and parole. It is unclear if the GSDOA has been fully implemented by police officers.

METHODS

We conducted 22 key informant interviews with police officers across British Columbia, Canada. Convenience sampling was initially employed, followed by purposeful sampling to ensure diversity in jurisdictions and participant demographics (e.g. age, sex, policing experience). A thematic analysis was conducted RESULTS: Our findings show that awareness and knowledge of the GSDOA vary among police officers. Many officers reported being unaware of the GSDOA or could not correctly define for whom and when the GSDOA applies. Information about the GSDOA was largely disseminated via email. Many officers expressed concerns with this dissemination method given the potential that key legal information would be overlooked. Police officers reported that not arresting for simple possession at an overdose was common practice, even before the enactment of the GSDOA. Thus, some officers did not believe that the GSDOA considerably changed police practices. Finally, police officers reported that they exercised discretion applying the GSDOA. Police officer interpretation of the intention and content of the GSDOA had critical implications for how they applied it in practice.

CONCLUSION

Effective education for law enforcement, including the dissemination of information beyond email, is needed to improve officers' awareness and understanding of the GSDOA. Given officers' use of discretion when applying the GSDOA, greater legal reforms, such as de jure decriminalization, may be required to fully protect persons at an overdose from simple possession for controlled substances.