“It’s Pretty Sad if You Get Used to it”: A qualitative study of First Responder Experiences with Opioid Overdose Emergencies

Abstract

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 towards 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.

Introduction

Between 1999 and 2020, the death rate from opioid-involved overdoses in the United States (US) increased over 700%, from 2.9 to 20.8 deaths per 100,000 people, totaling more than half a million deaths (1). In response, the federal government first declared the opioid crisis a public health emergency in 2017 and has renewed this declaration each year since (2, 3).

First responders provide medical and other supportive care to persons experiencing overdoses, playing a pivotal role in the opioid crisis in prehospital settings. These practitioners have a unique perspective on the overdose crisis as they may be the first and only source of professional medical intervention for at least some people experiencing overdoses. Previous qualitative work has reported that frequently treating patients who experience opioid overdose may contribute to experiences of work stress, burnout, and compassion fatigue (4-7). Mental illnesses such as post-traumatic stress disorder (PTSD), anxiety, and depression are more prevalent among first responders than the general public (8). Further, emergency medical services (EMS) personnel more frequently report experiencing burnout related to the opioid epidemic compared to other first responder subgroups (5). Given the exploratory nature of this emerging research base, additional qualitative findings can complement and enrich the limited existing findings.

This study aimed to better understand the experiences of and attitudes towards treating opioid overdose among a cohort of firefighters and EMS personnel, and the emotional effects, coping strategies, support systems, and views on policies related to the opioid epidemic. Amidst the ongoing and devastating opioid overdose crisis, understanding the experiences and attitudes of first responders and the effects of these calls is critical to a robust public overdose response strategy as it can inform policy-making, improve support systems for first responders, and positively affect patient care (9).

Methods

Study design and sampling

This was a cross-sectional, qualitative study (10) to broadly explore participant experiences (11). The semi-structured interview guide was developed based on the existing literature and feedback from experienced first responders and others in the Empirical Research Lab in the NIH Clinical Center Department of Bioethics.

The cohort was a self-selected convenience sample (10) of adult, English-speaking first responders. Each participant must have been employed by the Columbus (Ohio) Division of Fire as a firefighter/emergency medical technician or paramedic for at least a year, and have responded to at least three opioid-related emergencies to be eligible. This fire department was chosen because of its large size and the responsibility of serving a community with high rates of opioid-involved overdose and opioid use disorder (11, 12). The Columbus Division of Fire is the largest fire division in Ohio, staffed by over 1,500 uniformed personnel and a total of 35 fire stations covering the city of Columbus. In 2018, the Columbus Division of Fire’s 41 medic units responded to approximately 126,000 calls for service, and the overdose reversal drug naloxone was administered on 2,784 occasions (13).

Through a collaboration between the study team and leadership of the Columbus Division of Fire, requests for participants were sent to an all-users email group and posted on an online training platform for first responders. Participants were also encouraged to tell co-workers about the study to facilitate snowball sampling (10). An information sheet describing the study’s purpose and procedures was sent to the 20 individuals who contacted the researchers to express interest. Of those, 18 individuals scheduled and completed interviews.

This study was deemed exempt from review by the NIH Office of Human Subjects Research Protections (18-CC-00689). The Ohio State University institutional review board, with jurisdiction over the Columbus Fire Division, determined that no additional local review or exemption was required. The chief of the Columbus Division of Fire approved recruitment from the division. No personally identifiable information was collected. Participants were informed about the study and gave oral consent. Interview transcripts were stored in a secure database.

Data collection and analysis

Telephone interviews were conducted between September 2018 and January 2019 by one author (CH) trained in qualitative research. Interviews lasted 30 to 60 minutes. No compensation was provided. Interviews were recorded and transcribed verbatim.

One researcher (CH) reviewed the interview transcripts to develop a coding framework, which was then discussed among the other researchers (15, 16). Two researchers independently coded each transcript (CH, DW, or CG); disagreements were resolved via discussion among all three reviewers. Independent coding and discussion of findings among the authors helped to reduce potential bias (17). As new data were collected, an iterative approach was used to refine and finalize the coding framework. By the eighteenth interview, we determined that no new themes were likely to emerge and data collection had reached saturation (18). The coded data were analyzed using conventional content analysis, taking an inductive approach in order to identify emergent themes (13).

Results

Respondents (n=18) were predominantly male (n=17), all self-identified as White or Caucasian, and had a median age of 44 years (range 24-63 years). Respondents had a median of 18 years of first responder experience (range 1-40 years). The median self-reported number of opioid emergencies they responded to in the past year was 86 (range 12-300). Several participants provided an approximate range when asked to recall the number of emergencies they responded to in the previous year. For these data points, the midpoint of the reported range was used in calculating the group median.

Figure 1 below describes the first responders’ typical experience of treating patients during opioid emergencies.

Figure 1.

Participants’ typical experience treating opioid overdose.

Our results are grouped according to the following major themes: 1) numbing routines, 2) memorable and emotionally impactful experiences, 3) compassion, hope, and empathy, 4) frustration, coping, and burnout, and 5) moral commitment to helping patients [Table 1 below].

Table 1.

Emergent Themes.

Theme	Description
1. Numbing routines	First responders experienced responding to opioid overdoses as routine; for some, this numbed their emotional response and/or affected patient care.
2. Memorable and emotionally impactful experiences	Some types of opioid-related emergencies were particularly memorable and impactful, such as when young children are involved.
3. Compassion, hope, and empathy	First responders hold evolving beliefs about their patients, addiction, and substance use and many remain compassionate and hopeful despite the devastation of the opioid crisis.
4. Frustration, coping, and burnout	Frustration with the frequency of these emergencies, suboptimal treatment options, poor or underreported patient outcomes, and limited structural and societal solutions challenge first responder coping skills and leads, in some cases, to burnout and PTSD.
5. Moral commitment to helping patients	First responders express dutiful dedication to providing care and saving lives despite the demands of these and other emergencies.

1. Numbing routines

Almost all respondents described opioid overdoses as “run of the mill” and “routine” in nature. One participant said “[responding is] like second nature, opening your lunchbox to eat or something” (R11). As these emergencies are now more “commonplace,” some participants reported becoming “numb,” “callous,” and “desensitized” in their response.

I take these people to the hospital and I just have no emotions. I don’t care. It’s just a routine thing.

(R12)

In addition to increased exposure and competency in treating these emergencies, comprehensive guidance and well-scripted protocols meant that for some respondents, “the run itself is not a difficult run,” (R5) at least in terms of medical care.

However, the frequency of opioid-related emergencies affected some participants’ approach to patient care. For instance, while one respondent said these calls “run fairly smoothly” given the effectiveness of the opioid antagonist naloxone (also commonly known by the brand name Narcan), (R2) another worried that the frequency of calls may lead some first responders to “jump and give Narcan much quicker when [they] probably need to assess” (R14) whether an opioid overdose occurred.

We see it so often, like multiple times a shift, that I think we become – I don’t want to say complacent, but we come to expect that it’s going to be an overdose as opposed to it could actually be something different.

(R14)

2. Memorable and emotionally impactful experiences

While most opioid-related emergencies were experienced as routine, respondents noted certain opioid-related emergencies were especially memorable and emotionally impactful: calls that involved children, repeat patients, unexpected elements, or instances where first responders felt they had made a difference, for instance. [Table 2 below].

Table 2.

Most memorable experience: selected quotes.

Common type of memorable experience	Illustrative quote
Children on scene	When we get there, it was a…20-something female who was overdosed on the floor and her, I’d say, 8, 10, 12-month-old daughter who was climbing on her like a jungle gym. No one else at the house. It was just an overdosed mom and a 12-month-old baby. (R3)
Repeat patients	…[we] took her to the hospital once after having revived her with naloxone. And then two hours later, same situation, passed out in the backyard of this house and had to administer naloxone again and another trip to the hospital. (R13)
Surprising or unexpected	I would say the most memorable one was a woman that had overdosed and we had administered Narcan and once she came out, the first words out of her mouth were, she was telling a joke about, “What do you call a guy with no arms and no legs floating in a pool?” And the answer was Bob [laughter]. (R16)
Making a difference	…you can almost kind of tell in a sense that some people are struggling and want help more so than others … we kind of had a longer, more in-depth talk about things … he [the patient] told me some more personal things and I told him more personal things … those type of moments are big ones that stick in your mind. Or at least hopefully you make a difference in people’s lives sometimes. (R5)

Children featured prominently in many participants’ most memorable or emotionally impactful experiences:

I got to tell you, that really gets to me. I don’t let it out, I don’t let it show, but when there are kids involved, that right there – I will never understand how you put anything over kids. That’s just – that gets to me.

(R15)

One respondent recalled treating an 8-year-old who died after inadvertently ingesting an opioid. Another recounted “a call about a male that was found unconscious in his bathtub” and the caller was his 6-year-old daughter. Referring to this run, the respondent said, “that one still pops up from time to time when nothing’s on my mind.” (R6). Others’ recollections of memorable experiences involved repeat patients, others were memorable because they were surprising or unexpected, like people overdosing while driving or a patient who told a joke immediately after “coming back from the brink of death.” (R16)

Some experiences were described as memorable because they involved connecting with patients on a “more personal” basis, helping first responders feel like their efforts truly “make a difference” in a patient’s struggle with addiction. One respondent enlisted the help of relatives to encourage a patient to seek treatment. Another recalled connecting with a patient by sharing his own experience of witnessing a close relative’s struggle with addiction. Referring to this encounter, the respondent said this encouraged the patient to seek treatment, and “helped him realize that there’s other people out there that are struggling with that and it’s not just him.” (R5)

3. Compassion, hope, and empathy

Many respondents expressed compassionate views about patients and said their beliefs about opioid addiction had evolved over their careers, leading to increased compassion in patient interactions. A few participants described the opportunity to listen to patients’ stories about their lives and struggles with addiction as especially meaningful. One respondent recalled the following encounter:

…both her parents were big heroin users, and they sold her for sex to get money to support their heroin addiction…So to me, that was among the most powerful stories I’ve ever heard of. That if your own parents sold you like that for drugs, for their addiction, that to me is just, wow, that really put things into perspective for me of how addictive that drug is.

(R10)

Likewise, one participant who lost a close friend to an opioid overdose said sharing this experience helped patients feel less stigmatized.

And a lot of times when I offer that experience with it, they kind of look at me in a different light and think, “OK, maybe this person’s not just treating me like a number, maybe this person actually cares.”

(R2)

Other respondents described feeling increased compassion towards patients and empathizing with their families because “when you realize that everybody is somebody’s son or daughter. You have a little more empathy, I think.” (R16) All but one participant had a friend or relative who dealt with an opioid addiction or knew a co-worker who did. One person said “you’d be hard pressed to find… that we don’t know somebody that’s been affected.” (R18)

It’s the same for us as it is anyone else. People think just because we deal with [substance use] daily, that we’re maybe immune to it, but we’re not.

(R3)

While these respondents recognized the scale of the crisis, they were hopeful to “start seeing the downward trend sometime soon.” (R5) One respondent shared the following poignant narrative about hope:

[There’s a] kid on a beach with starfish. And he’s going along and the tide’s going out, the tide’s receding, and he’s throwing the starfish out into the ocean. And the parent goes out and says, “What are you doing? Why are you throwing those out there? You know you can’t save them all.” And he picks one up and says, “But it matters to this one,” and throws it out. And then picks up the next one, “It matters to this one,” and throws it out. And that’s kind of at least how I look at it: Am I going to be able to fix the opioid epidemic nationwide? No. Can we fix one person at a time? Maybe. Can we at least save people? Yeah. And all you can do is try.

(R6)

4. Frustration, coping, and burnout

Almost all respondents expressed frustration with perceived limitations on their ability to affect long-term patient outcomes and many agreed with the following statement from one Ohio politician:

First responders are reaching a new level of frustration responding to multiple calls, for repeated victims, and they just don’t feel like they’re making progress.

(19)

Characterizing the causes and effects of this “new level of frustration,” one respondent said:

…first responders are frustrated in that nothing’s changing, and we have mental health issues because of it… guys have depression. Guys have certain levels of PTSD.

(R8)

Many respondents noted that “it doesn’t feel like [they’ve] gotten any more of a handle on” (R3) the epidemic over the years. Treating patients’ acute overdose symptoms with little to no expectation of improving the root cause of the issue led to feelings of helplessness, as it goes against a core principle held by many first responders: “to take a situation and fix it and make it better.” (R2)

People always talk about Narcan being a lifesaving drug; in my experience, it’s a life-extending drug. It doesn’t stop the behavior… it doesn’t solve the problem at its base.

(R7)

This perceived inefficacy seemed to have a negative cumulative effect over time, leading in some to compassion fatigue (R13), hopelessness, demoralization, desensitization to patients, and burnout. A lack of feedback about the effects of their actions also contributed to these sentiments.

So you feel like, “Did I make a difference? I don’t know.” There’s no follow-up, and we’ve constantly told them that. Because firemen are people that if they see results, we’re all in. We’ll pour resources into it … We’ve never heard of one person yet that’s ever successfully completed the rehab program. Nothing.

(R18)

Respondents said they coped with the stress of opioid-related emergencies by talking about calls with others, creating boundaries between work and home life, and practicing general healthy habits and stress relief. A few respondents said they make a point of not letting calls bother them and emphasized that “there’s nothing that you can really do to change” (R7) the situation. Other coping mechanisms include what one respondent called the “wrong way” such as heavy drinking or using “sick fireman humor” – telling “less than politically correct jokes” (R13) about patients and substance use.

That’s kind of how firemen deal with things is to kid and joke about them and not take it to heart, you know what I mean? Because if [you] did, it would eat you up.

(R17)

Several participants said first responders are encouraged to attend “stress debriefings” after difficult calls but time constraints and cultural attitudes about help-seeking impeded this effort for some.

Because there’s still that stigma and attitude that, “If something bothers you, you’re soft.” And you have to be hard. You have to be tough to ignore it. And so we don’t talk about it, and then it just, you know, you bury it.

(R2)

Most respondents said they had not considered retiring or changing jobs because of stress related to opioid emergencies, with one respondent arguing that “anybody that would retire because of these runs probably shouldn’t have been in the industry in the first place.” (R16) In contrast, some shared that the cumulative emotional effects of these and other emergencies had led them to seek temporary transfers to lesser-affected areas. Some participants felt first responder psychological health was being under-addressed.

Everybody is focused on the addict … But they’re not the only ones that are affected. … nobody’s really asking if we’re OK. And it’s messing guys up, seeing that same shit all the time. It’s pretty sad if you get used to it.

(R2)

Some responders felt that “there’s only so much a textbook and instruction in the classroom can teach,” (R3) and endorsed more informal training like “learning under fire” (R3) or from personal and peer experiences. Guidance on soft skills such as talking to patients, connecting them to resources, and effectively convincing them to seek treatment was less explicit and often unscripted.

5. Moral commitment to helping patients

In spite of their frustrations, several respondents felt that it is not their “job to solve this problem” (R8) and that the issue is systemic and “so much bigger than [them].” (R6) Many respondents spoke about their commitment to individual patients, saving lives, and doing what emergency responders are trained to do. Several said there was nothing they would change about their response to these emergencies, that they rarely felt unable to do whatever ought to be done to treat patients, and stressed that despite their frustration with policies and the lack of stricter consequences for patients, their role entails an obligation to treat.

There’s nothing I would change… Ethically or medically, there’s nothing. If somebody’s not breathing, then our job is to help you breathe. If your heart’s not beating, my job is to get your heart to restart.

(R12)

Still, some comments suggest first responders struggle with knowing whether they “did enough” for a patient post-call. For instance, one responder recalled an experience where he gave up trying to convince a patient to accept transport to a treatment center after the patient refused his initial request. Later witnessing a police officer on scene successfully convince the same patient to accept an offer to transport made this respondent question if he is “saying the right things to the right person at the right time.” (R10)

…he [the officer] wouldn’t take no for an answer and just kept talking to him [the patient], … and then finally he [the patient] changed his mind and we took him to [a treatment center] … that kind of opened my eyes to maybe try to keep pushing just a little bit more.

(R10)

At the same time, a few respondents favored more punitive measures as part of a “tough love” approach aimed at holding patients more accountable for the effects of substance use on their lives, their relatives, and their communities.

…if you raise your child and your kid wants to stick a paper clip in an outlet, you’re going to freak out and get mad at them and try to scare him not to do that because you’re going to die… That’s what we need. You don’t need to treat these people like criminals, but you need to be tough on them and say, “Look, no, you’re not doing this drug anymore.”

(R12)

Others, while similarly in favor of increased personal responsibility on the part of people who use drugs, reiterated their commitments to saving their patients’ lives.

I can see it both ways. Because if the people aren’t doing anything to help themselves, it gets a little tiresome to go help them. But again, who wants to sit on your hands when somebody’s dying and you have the tools to help them?

(R17)

This sense of moral commitment to patients emerged strongly in response to the idea of implementing a “three strikes” rule, as suggested by one Ohio politician. (20)

The first two times a person overdoses, that person would have to pay back every cent by performing community service. If that same person overdoses a third time, but has not completed community service, an ambulance will not go out to help.

(OH politician, paraphrased in news article)(20)

While two agreed with the sentiment expressed, all participants raised issues with this approach, stressing that their job was to save lives. Many respondents instead emphasized the need for policies designed to address the supply of prescription and illicit opioids and to create better access to and integration of available treatment services like inpatient treatment centers. Some respondents also argued for increasing involuntary hospitalization to treat addiction and reduce recurrent overdoses.

Discussion

Our findings are largely consonant with previous work: first responders consistently express confidence in their abilities to treat overdose emergencies, but note an increase in feelings of compassion fatigue, burnout, and helplessness (4-6, 9, 21-24). Strong professional and moral commitments coupled with increasing instances of what Corrigan et al. (25) call “optimal contact,” i.e., instances of positive interpersonal interactions between patient and practitioner, have also been previously reported (4-6, 9, 21-25). However, our analysis supplements the existing research base in several key ways.

Firstly, although others including Williams-Yuen et al. (21) and Saunders et al. (22) have also reported on the interesting contrast between first responders’ descriptions of opioid overdose emergencies as routine despite being emotionally impactful, it is unclear what factors explain this apparent contradiction. Nicholson et al. report that first responders view these emergencies as high-stress traumatic situations that can lead to burnout and PTSD over time (6). Our findings suggest that being able to provide only what they deemed as short-term solutions coupled with a perceived helplessness in ‘solving’ the crisis may also contribute to these and other adverse psychological effects, also noted by Metcalf et al. (9). Perceived self-inefficacy has a noted association with burnout across many professions and, in our view, is compatible with the common sentiment among these first responders that these calls are routine (26). As a result, increased efforts to reduce overdose emergencies and remove barriers to seeking treatment may, in addition to improving patient outcomes, have the added benefit of improving first responder job satisfaction.

Secondly, although our analysis suggests little evidence of moral distress as it is traditionally defined (i.e., as occurring when one knows the morally correct action or decision but, due to internal or external constraints, cannot pursue it), we did find evidence of moral distress in a broader sense: reports of experiencing negative emotions from involvement in a situation perceived to be morally undesirable. The majority said they had never been faced with a situation where they were unable to do what they felt ought to be done to treat a patient, yet the frustration and compassion fatigue they report could be a kind of moral distress (27). These responders are committed to saving lives and feel that they were doing the morally right thing, but are doing so in circumstances they perceive to be morally undesirable. With only one exception, reports of moral distress among first responders to opioid related emergencies have not been highlighted in the literature but, given its likely co-occurrence with compassion fatigue and burnout, further assessment of this phenomenon seems warranted (6, 28, 29).

Respondents were compassionate towards patients with substance use disorders despite feeling conflicted about patients’ drug use and the myriad contributing factors. This complements findings from Metcalf et al. (9) who found that compassionate emergency personnel held a commitment to professionalism that superseded personal biases. Also consistent with Metcalf et al. (9), expressing compassionate beliefs seemed to lead to more positive patient interactions based on some participants’ own self-report. Indeed, others have noted that patients who perceive a lack of compassion and/or the presence of stigmatizing attitudes from emergency personnel could have worsened treatment outcomes and are more likely to refuse follow-up treatment (30, 31). However, this association was less salient in our study: the strong moral commitments expressed by respondents – including those who self-identified as callous or desensitized – seemed to trump any personal bias that might impede providing optimal care. However, the authors also note that people who use drugs may perceive professionals who treat them merely out of a sense of duty or devoid of empathy as stigmatizing (9, 32).

Limitations

Our small, racially homogenous sample is not representative of responders in Ohio or other locations in the U.S. Additionally, we used a self-selected convenience sample, which further limits the generalizability of our findings and raises the likelihood of selection bias, with those most interested in the topic volunteering to participate. Nonetheless, the powerful descriptions of these first responders’ experiences and frustrations are likely to resonate with other first responders, especially those in urban areas with high rates of opioid overdose emergencies. The overlap in the major themes described here and elsewhere in the literature further supports the reliability of these findings. Social desirability biases may have affected participants’ willingness to share certain views, although we did not collect any identifying information or attribute responses to individuals. These interviews were conducted prior to the onset of the COVID-19 pandemic, a global crisis that placed frontline workers at increased risk and indirectly contributed to increases in overdose emergencies, further burdening emergency response systems (33, 34). Additionally, the opioid crisis continues to receive increased public attention and, in recent years, there have been several key shifts in federal and state political rhetoric. New policies have been introduced and courts across the country have ordered drug manufacturers and distributors to pay large sums to settle suits filed for their role in the opioid crisis (35, 36). These developments are likely to have affected the experiences and/or views of many participants. Limitations notwithstanding, our study contributes an important perspective from persons essential to our response to an evolving and worsening opioid crisis.

Conclusion

Our findings indicate that first responders who routinely treat people experiencing opioid overdoses hold complex and seemingly conflicting perspectives on these emergencies and the opioid crisis more broadly. They experience opioid overdoses as routine and numbing, yet emotionally impactful. They describe a growth in compassion with experience, but also compassion fatigue. They express a strong moral commitment to their role in saving lives, and at the same time frustration with a system and societal response that seems inadequate to the problem. These findings suggest a critical need for continued improvements in the prehospital emergency care system, macro-level societal changes that might result in better treatment outcomes, and preventative strategies to battle the crisis. Furthermore, addressing gaps in occupational support for first responders will likely improve their emotional wellbeing and may further result in improvements in patient outcomes in the prehospital setting.