From April 2020 to April 2021, over 100,000 people in the United States died of a drug overdose, the vast majority caused by consumption of opioids. Reference Rabin1 Though a stigma toward people with substance use disorder exists, some policy interventions during the opioid crisis have focused on harm reduction rather than criminal justice punishment. For example, naloxone—an opioid overdose reversal drug—has become a common tool for Emergency Medical Services (EMS) providers and law enforcement workers to use to save the life of someone experiencing an overdose. Reference Baumgart-McFarland, Chiarello and Slay2 As essential points of contact between clients with opioid use disorder and the state, these first responders make decisions and act in ways that significantly affect the lives of marginalized clients who use drugs. Reference Baumgart-McFarland, Chiarello and Slay2,Reference Pike, Tillson and Webster3 Viewpoints first responders hold regarding whether clients with substance use disorder deserve medical rehabilitation or criminal justice punishment significantly influence whether these clients receive appropriate medical treatment, whether they are referred to substance use treatment, and whether they are treated with compassion. Reference Baumgart-McFarland, Chiarello and Slay2,Reference Formica, Apsler and Wilkins4 To complicate matters, the EMS-providers and law enforcement workers responding to overdose calls may have indirect and direct experiences with addiction themselves.
But to the authors’ knowledge, little is known about how the on-the-job and personal experiences of first responders influence their viewpoints on whether clients with opioid use disorder deserve medical rehabilitation rather than punishment through the criminal justice system. The goal of this article is to present preliminary findings on this association, drawing from survey data from a broader project on the lived experiences of first responders and opinions about clients with opioid use disorder.
Methods
This study relied on original survey data collected from August 29 to November 9, 2022. Electronic surveys were sent to all county and municipal fire, EMS, and police chiefs contained in the National Public Safety Information Bureau’s Safety Source sampling frame. The sampling frame included contact information for agencies in all 50 states across the United States. Each agency head was asked to take the survey and forward it to their employees. In all, the survey was sent to 21,360 fire and EMS agencies and 13,558 law enforcement agencies, with fire agencies that did not provide EMS dropped from the analysis.
For the dependent variable—client deservedness—the survey included a question on whether respondents felt clients with opioid use disorder deserve medical rehabilitation (such as substance use treatment) rather than punishment through the criminal justice system. This variable was coded on a 5-point Likert-type scale ranging from 1 = strongly disagree to 5 = strongly agree. To capture first responder on-the-job experiences during the opioid crisis as key independent variables, respondents were asked how many times they responded to overdose calls in the past year, as well as how many times they administered naloxone, both coded categorically with answers ranging from 0 = 0 to 5 = 41+. For personal experiences, respondents were asked two questions: one on whether they had close friends who have experienced an addiction to opioids or nonopioids, and one on whether they have family members with this experience. An additional personal experience question asked whether respondents feel addiction has had a direct impact on their lives, coded on a 5-point Likert-type scale. Control variables were operationalized by means of questions on respondents’ agency type, age, gender, ideology, education, and race/ethnicity.
The survey included an informed consent form on its opening page. The consent form informed participants that they could opt not to take the survey or terminate it at any time. The research protected confidentiality at the individual and organizational levels, as survey respondents could not be paired with their responses or agencies. The project was deemed to be exempt by Florida Atlantic University’s Institutional Review Board (Package # 1860822-1).
To analyze the data, descriptive statistics were first examined, before using ordinal logistic regression to understand the relationship between the explanatory variables and the ordinal variable client deservingness. For ease of interpretation, the analysis treated ordinal explanatory variables (eg, overdose calls and direct addiction) as continuous if their categories were roughly evenly spaced. Odds ratios, confidence intervals, P-values, and statistical significance were reported. Statistical analyses were performed in Stata 18.
Results
Of those who responded to questions on all variables of interest, 2722 were EMS-providers and 1114 were law enforcement, totaling 3836 first responders for the final analysis. Results for descriptive statistics are contained in Table 1. Variables treated as continuous display means and standard deviations, whereas those treated as categorical have percentages. Most respondents (63.56%) either somewhat agreed or strongly agreed that clients who use opioids deserve medical rehabilitation rather than punishment through the criminal justice system. The mean for overdose calls was 1.928, and for naloxone administration, it was 1.436, both falling between the 1 = 1–10 times and 2 = 11–20 times categories. With regard to having family members or close friends who have experienced an addiction to opioid or nonopioid drugs, 53.7% of respondents had a family member with addiction experience and 42.49% had a friend who had experienced an addiction. The mean of 3.616 for direct addiction indicates that respondents were more likely to agree that addiction has had a direct impact on their lives than to disagree with this statement. Most respondents were EMS-providers (70.96%), male (84.93%), had some college experience (50.81%), or were non-Hispanic white (86.55%), while a plurality was conservative (48.15%). The mean age of 4.372 fell between the 35 and 44 years old and 45 and 54 years old categories.
Table 1. Summary Statistics (N = 3,836)
Table 2 displays results for the ordered logistic regression model with client deservedness as the dependent variable. Results show that of the on-the-job experiences, only the overdose calls variable was significant, displaying a negative effect on client deservedness (odds ratio [OR] = .932; 95% confidence interval [CI]: .873-.996). With regard to personal experiences, relative to respondents who did not have a close friend with addiction experience, those who had a friend with an opioid problem had 25% greater odds of rating clients with opioid use disorder as deserving of medical rehabilitation (95% CI: 1.063-1.469), and those who had a friend with a nonopioid problem had 30.4% higher odds (95% CI: 1.116- 1.523). Those who agreed addiction has had a direct impact on their lives had more positive views of clients (OR = 1.084; 95% CI: 1.032-1.138).
Table 2. Ordered Logistic Regression Results (N = 3,836)
***p < .001, **p < .01, *p < .05.
Results for associations between the control variables and client deservedness illustrate more positive views of clients among females relative to males (OR = 1.494; 95% CI: 1.255-1.780), moderates relative to conservatives (OR = 1.659; 95% CI: 1.464-1.881), and liberals relative to conservatives (OR = 5.183; 95% CI: 4.138-6.491). Conversely, law enforcement respondents had lower odds of rating clients with opioid use disorder as deserving relative to EMS-provider respondents (OR = .52; 95% CI: .452-.599).
Limitations
Limitations of the current study include an overrepresentation of white non-Hispanic first responders in the sample, something future studies can address with more representative samples. In addition, those who took the survey may have different views on people with opioid use disorder relative to those who did not. These limitations were addressed by reducing non-response error through multiple contacts with potential survey respondents and pilot testing to improve survey accessibility. Further studies can use observational rather than self-report data, in addition to collecting data on the organizational characteristics of first responder agencies to see which departmental-level factors have an influence.
Discussion
Despite these limitations, the strengths of the current study include the use of the survey instrument to obtain a wide range of viewpoints from first responders across the United States, with a large sample size and much variation in responses. With this method, the analysis provides a better understanding of how first responders’ on-the-job and personal life experiences influence their perceptions of clients who use opioids, as well as exploring the salience of demographic characteristics. Given that these public servants play such a crucial role during the opioid crisis, the survey’s focus on client deservedness can help to enhance overdose response, services offered to clients, client outcomes, community relations, and working conditions for first responders.
The opioid crisis has had a massive impact on first responders. They have been tasked with responding to overdose calls and reviving people from overdose while simultaneously coping with addiction-related issues indirectly and directly in their personal lives. Regarding personal experiences, the current study demonstrates that having close friends who have had a problem with either opioid or nonopioid drugs has a positive effect on viewpoints first responders hold regarding clients with opioid use disorder, as does believing addiction has had a direct impact on respondents’ lives. Hence, creating spaces where these public servants can interact with people in recovery, or with people who use drugs, can help to foster positive relationships and reduce negative feelings first responders may have. In this way, positive community relations can be promoted, as can compassionate care—1 of the goals of some EMS-provider and law enforcement agencies. Reference Beersdorf5,Reference Bossert6 In Vancouver, Canada, discussions on substance use include members of the community who use drugs or who have previously used drugs, resulting in the representation of a population normally excluded from decision-making. Reference Jozaghi7 EMS-provider and law enforcement agencies in the United States could consider a similar model to foster a shared understanding between public servants and this marginalized population.
In addition to the positive effects of personal experience, results reveal that responding to overdose calls predicts negative opinions about the clients experiencing these overdoses. That is, the more first responders respond to overdose calls, the less likely they are to view clients with opioid use disorder as deserving of medical rehabilitation rather than punishment through the criminal justice system. A possible reason for this is the “compassion fatigue” and burnout which may occur alongside frequent overdose call response; this is especially likely to happen if these calls repeatedly involve the same individual. Reference Winstanley8 To reduce the chances of being overwhelmed by the emotional weight of reviving clients from overdose, and to cope with emotional exhaustion, first responders may reduce their compassion over time and lessen their capacity for empathy. Reference Baumgart-McFarland, Chiarello and Slay2
To combat such fatigue, burnout, and negative viewpoints about clients who use opioids, first responder training and education can incorporate lessons on wellness, stress regulation, and emotional wellbeing. Reference Pike, Tillson and Webster3,Reference Winstanley8 In addition, better funding for substance use treatment programs and other harm reduction services which can reduce rates of overdose could benefit clients and first responders, as can anti-stigma trainings which educate public servants on topics related to drug addiction. Reference Baumgart-McFarland, Chiarello and Slay2,Reference Winstanley8 For example, the National Institute of Environmental Health Sciences (NIEHS) developed an Opioids and the Workplace Training Tool for workers in high-risk occupations who are affected by the opioid crisis—eg, emergency responders, law enforcement, and health-care workers. 9 This training includes lessons on opioid use and misuse in the workplace, understanding opioid use disorder, and stigma related to addiction. 9 Research has shown that these lessons have helped to empower workers, reduce stigma, and drive organizational change. Reference Persaud, Afable and Geer10 Instructors have addressed stigma by educating trainees on opioid use disorder, incorporating the audience’s personal experiences with opioids, substance use, and addiction. Reference Persaud, Afable and Geer10
As demonstrated herein with the positive effects of the direct addiction variable, training could focus on making first responders aware of the impact addiction has had or can have on their lives. The NIEHS’s training tool could also help to this end by using the direct experiences of those in the audience to make first responders aware of the impact of addiction. 9 In addition, such training is useful for substance use issues in the workplace, an important consideration in first responder organizations, where pressure from crises and burnout leads to problematic substance use. Reference Witkowski, Lofaro and Headley11 The negative viewpoints of law enforcement, male, and conservative respondents in the current research indicate that these populations may be good targets for trainings related to the opioid crisis and substance use.
It is important to be aware of the occupational challenges first responders face. These public servants regularly experience anxiety, posttraumatic stress, depression, and burnout as a product of frequently responding to distressing and chaotic situations. Reference Alshahrani, Johnson and Prudenzi12 Overdose response does not happen in a vacuum; those responding are often coping with multiple hazards and stressors simultaneously. For example, increased stress can occur when the law enforcement and EMS providers responding to overdose calls fear that they may overdose from touching fentanyl, a fear driven by miscommunication and misinformation. Reference Persaud and Jennings13 Regulating emotions and displaying compassion for clients who use drugs while managing such complex situations is a challenging task. Training and education programs should take this complexity into account and aim to improve problems related to substance use disorder for those using substances and those responding to substance use-related calls. Improving first responder viewpoints regarding the deservedness of clients with opioid use disorder could help public servants to better understand client medical needs and administer naloxone in a timely and effective manner, as well as to be more willing to refer clients to substance use treatment programs. Reference Baumgart-McFarland, Chiarello and Slay2–Reference Formica, Apsler and Wilkins4
Conclusions
Findings from the current study illustrate that first responders who respond to more overdose calls are less likely to agree that clients with opioid use disorder deserve medical rehabilitation relative to those responding to fewer calls. However, indirect and direct personal experiences with addiction positively influence first responders’ opinions. This calls attention to the need to provide better education and training to these public servants with the goal of helping them to understand the complexities of addiction and to manage their emotions surrounding on-the-job experiences with addiction-related issues. In addition, spaces should be created where first responders can have positive interactions with people who use drugs or who are in recovery, thus improving community relations and enhancing compassion for oft-marginalized clients.
Author contributions
R.L. and A.S. conceptualized the study and designed the survey. R.L. served as the primary data analyst and drafted the manuscript. A.S. assisted in writing the manuscript and made major edits and contributions.
Funding statement
This research was partially funded by the Florida Atlantic University 2022 Graduate Student Thesis and Dissertation Scholarship Award.
Competing interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this study.
