“You might be nice, but where you take me, they’re not gonna be”: Preferences for field-based post-overdose interventions

Abstract

Introduction:

Emergency medical services (EMS) systems are piloting interventions to respond to overdoses with additional services such as leave-behind naloxone and medication for opioid use disorder, but little is known about the perspectives of people who use drugs (PWUD) on these interventions being delivered by EMS during an overdose response.

Methods:

The Consolidated Framework for Implementation Research guided the development of data collection tools, the analytic strategy and the organisation of results. A community engaged method was used which included both academically trained researchers and community trained researchers who are also PWUD. This study used semi-structured interviews to gather data from 13 PWUD in King County, Washington in June 2022. Data were analysed using thematic analysis.

Results:

The people interviewed for this study viewed EMS distribution of leave-behind naloxone and field-based buprenorphine favourably. They viewed EMS facilitation of hepatitis C virus and HIV testing in the field less favourably and were concerned about stigmas associated with those results. Additional themes emerged regarding: the need for different approaches to post-overdose care; the need for new services, including post-overdose trauma counselling and an alternative destination to the emergency department; and the harms of law enforcement presence at overdose responses.

Discussion and Conclusions:

This study found strong support for leave-behind naloxone and field-initiated buprenorphine. Further training for EMS should include trauma-informed care and strategies to address burnout and increase compassion. Alternatives to the emergency department as a post-overdose destination are needed. These strategies should be considered by jurisdictions revising overdose response protocols.

1 |. INTRODUCTION

Up to 40% of individuals who die of overdose have at least one emergency medical services (EMS) encounter in the year before their death, indicating a brief and critical window of opportunity to reduce the risk of opioid overdose and mortality for people who use drugs (PWUD) [1]. As such, EMS settings are prime environments for the implementation of evidence-based medical interventions due to the universality of the services provided and the low barriers to access.

EMS systems in the United States and beyond are piloting evidence-based medical interventions to prevent opioid overdose death and increase access to care for PWUD, such as leave-behind naloxone and initiation of and access to buprenorphine treatment [2–7], and some mobile clinic teams are offering HIV/HCV testing in similar contexts [8]. Distribution of leave-behind naloxone (LBN) is cost-effective [9] and reduces opioid-related fatalities [7, 10]. Medications for opioid use disorder like buprenorphine similarly reduce opioid-related morbidity and mortality [11]. Moreover, HIV/HCV testing for PWUD improves access to care [12]. This package of interventions has documented efficacy in emergency rooms [5, 6] and community clinics [8, 13] while demonstrating feasibility during brief encounters with street medicine teams [9, 14, 15]. Despite their effectiveness, these interventions are not offered in many systems [16, 17] and have only recently begun being considered for implementation in EMS settings. Data on the perspectives of PWUD on these interventions delivered by EMS are limited.

Leave-behind naloxone programs refer to the provision of emergency naloxone kits to non-medical personnel and training in overdose management, administration of naloxone and after-care [18]. EMS distribution of naloxone kits to overdose survivors and their social networks increases the availability of naloxone in high-risk communities [19, 20]. There are overwhelming data on the effectiveness of naloxone distribution programs [18, 21], which are associated with decreased mortality in PWUD [22]. PWUD have expressed strong support for LBN programs in their communities and willingness to participate in training programs and naloxone administration when necessary [23–26]. There is no evidence of compensatory drug use risk behaviour (i.e., more risky use because overdose reversal medication is available) after receiving LBN [27]. Although it is clear that LBN programs are highly effective and supported by PWUD, it is unclear how PWUD would react to implementation and delivery of such a program in a post-overdose EMS setting.

Medications for opioid use disorder such as buprenorphine are the gold standard for treatment [28–30]. There is robust evidence that maintenance therapy with buprenorphine promotes retention of PWUD in treatment, suppression of illicit substance use [31], and substantially lower risk of all-cause and overdose-related mortality [32, 33]. Many PWUD have expressed interest in buprenorphine as a treatment option [34, 35]. Field-initiated buprenorphine or prehospital buprenorphine treatment occurs when EMS administer buprenorphine to patients in opioid withdrawal [36, 37]. Because overdose patients frequently refuse transport to the emergency department and may not initiate buprenorphine in the emergency department [38–40], field-initiated buprenorphine addresses an important gap in care and may reduce the risk of future overdose [14, 36]. PWUD have expressed that telehealth or mobile units would be acceptable for providing access to buprenorphine [41, 42], but there are very limited data on PWUD perceptions of acceptability and utility of such programs delivered by EMS.

Existing data indicate that HIV/HCV testing remains an unmet need for some PWUD and providing such services can improve access to care overall [12]. Limited information is available on PWUD perceptions of HIV/HCV testing in post-overdose care settings, and testing often remains restricted to specialised clinics or mobile medical services [12]. This package of interventions (LBN, field-initiated buprenorphine and HIV/HCV testing) has documented efficacy in emergency rooms [5, 6] and community clinics [8, 13] while demonstrating feasibility during brief encounters with street medicine teams [9, 14, 15]. The integration of take-home naloxone, buprenorphine treatment and HIV/HCV testing into EMS programs post-overdose could dramatically increase access to these critical interventions if deemed useful and acceptable to PWUD, but this has yet to be tested in Washington State.

Since the inception of the local nonfatal overdose surveillance in 2018, the Medic One/EMS system in King County has seen steady increases in the annual volume of probable overdoses [43]. In addition to being a national leader in paramedicine, King County connects certain emergency services callers to appropriate health and social services through an alternative EMS program known as Mobile Integrated Healthcare. Although EMS staff have historically provided important referrals to community resources, most EMS responses in King County do not offer three medical services that have the potential to reduce overdose death and increase access to care for PWUD: (i) distribution of LBN; (ii) treatment with buprenorphine; and (iii) access to HIV/HCV testing. Research is needed to study PWUD perceptions of these interventions and how they can be adapted to improve acceptability and appropriateness before their implementation, as this study was designed to do. Critically, this study offers PWUD perspectives on evidence-based interventions that were previously unknown and demonstrates the importance of integration of people with lived and living experience into the co-design of care systems. Recent acquisition of funding to support EMS-related interventions to improve care for PWUD in King County make such understanding both timely and relevant to local decision makers and EMS leadership, and utility of the results may extend across North America and internationally as these programs become more widespread.

2 |. METHODS

2.1 |. Community-engaged approach

Grounded in community engaged research principles [44], this research was conducted by the Research with Expert Advisors on Drug Use (READU) team, a group of academically trained researchers and community trained researchers with lived and living experience of substance use. Our study structured its approach using community engaged research principles, we practiced reflexivity, and centred the perspectives of people with lived and living experience of drug use and EMS system involvement in its study design, execution and analyses. The READU team has ongoing discussions regarding the ethicality of the research and the potential for harm to the community, in addition, each week each member of the team has the (paid) opportunity to share an individual written or verbal reflection about the work with the rest of the team. Reflections are open to include whatever team members want to share and cover many topics but routinely centre on themes of power sharing, social location, positionality, role conflicts, partnership dynamics, the potential for bias, and thoughts on accountability and transparency in the research. Additionally, at weekly meetings reflexive prompts (specific to the stage of the project) are used to facilitate group discussion on how we as researchers may be influencing the research process and ways to identify and mitigate the bias introduced by ourselves and our respective positionalities. Prior to starting data collection, we engaged in bidirectional training during which community trained READU members educated the academically trained researchers on effective outreach strategies and experiences with past studies, whereas academically trained researchers shared knowledge about qualitative study design and analysis.

2.2 |. Theoretical framework

This study was grounded in the Consolidated Framework for Implementation Research (CFIR) [45], an implementation science framework that outlines a set of “constructs” situated within “domains” that are critical to investigate to simplify processes, determine barriers, highlight facilitators and identify strategies for implementation. This framework provided structure for the interview guide, deductive coding and thematic analysis, which highlighted various constructs as perceived facilitators (e.g., non-stigmatising environment and rapport building) and barriers (e.g., lack of access). For example, in drafting the interview guide, we used the CFIR to ensure questions covered each domain (e.g., intervention characteristics, outer setting, inner setting, characteristics of individuals, process) and probes guided deeper understanding about barriers and facilitators to PWUD receiving these interventions in EMS settings (see Appendix A). When creating an initial draft of the codebook, we used the CFIR domains for conceptual categorisation of the codes arising from the data (see Appendix B for a list of codes and corresponding CFIR categories).

2.3 |. Recruitment

We conducted qualitative interviews with PWUD who had experienced or witnessed an overdose response to better understand experiences with EMS overdose response and the feasibility and acceptability of three proposed interventions (LBN, field-initiated buprenorphine and HIV/HCV testing) in the post-overdose emergency-response setting. Participants were recruited using convenience sampling, in person, from three different community service locations across King County. Additionally, recruitment flyers and information regarding the study were shared with the participating community service locations. Interested PWUD were screened for the inclusion criteria which required study participants to have experience with opioid use, speak English, be above 18 years of age and have had an EMS encounter in the past 12 months. Participants who met the inclusion criteria were invited to participate in the study interviews. Participants were given a $50 gift card for their participation.

2.4 |. Data collection

Individual interviews were conducted in private settings at the community service locations, where either 1 or 2 members of the research team interviewed a single participant. Interviews lasted between 20 and 45 minutes and were audio recorded and transcribed. Interviews were continued until saturation was reached, that is, the point at which no new data or themes were emerging, and the new data were a repetition of previous data. We contemplated the possibility of saturation as a team after three separate occasions of data collection. The determination was made at a team meeting, by reading sequentially through transcripts of the interviews conducted and discussing what topics arose for each conceptual area, determining that topics in later interviews were redundant with those elicited in earlier interviews. We asked structured questions on participants’ age, race/ethnicity, gender, drug of choice, frequency of use and length of time using drugs to capture demographics and substance use characteristics. Semi-structured interview questions covered opinions about the evidence-based interventions being studied, experiences with EMS, preferences for service delivery, and experiences witnessing and responding to overdose. Refer to Appendix A for a summary of interview guide questions and probes.

2.5 |. Analysis

Qualitative interview data were analysed using the six phases of thematic analysis [46] which began with members of the READU team reviewing the transcripts for accuracy and noting initial impressions, observations and insights during the data familiarisation phase. A hybrid deductive-inductive approach was used for codebook creation wherein the team grouped observations and insights from transcripts inductively into initial codes, adding codes derived deductively from the CFIR framework literature, interview guides and research questions. Both the inductive and deductively generated codes were then organised within CFIR [45] domains to create the preliminary codebook. The members of the READU team engaged together in line-by-line group coding first of a single interview, using Dedoose software and the preliminary codebook, any disagreements in code applications were identified and reconciled as a group. The codebook was revised during the first round of coding: some new codes were added, whereas others were modified, deleted or regrouped. The finalised codebook (see the finalised list of codes provided in Appendix B) was then applied individually by members of the READU team to the datasets through a round of primary line-by-line coding. After primary coding was completed, each transcript was coded by another researcher to improve trustworthiness. Disagreements in code applications were reconciled as a team.

3 |. RESULTS

We conducted n = 13 semi-structured in-depth interviews with PWUD in May and June 2022. As a way to mitigate re-traumatisation, participants were not explicitly asked if they had used opioids and if they themselves had experienced an overdose event; however, based on participant’s interview responses it was clear to the research team that all participants had used opioids at some point in their lives, and similarly, all participants had experienced an overdose.

Participant demographics are shown in Table 1.

TABLE 1.

Participant demographics (n = 13).

Demographics	n
Age, years
26–35	6
36–45	4
46–55	1
Prefer not to say	2
Race/ethnicity
Hispanic/Latino	2
American Indian/Alaskan Native	1
Mixed race	3
White	4
Prefer not to say	3
Gender
Male	8
Female	2
Non-binary/gender non-conforming	1
Prefer not to say	2
Most frequently used substance
Fentanyl	4
Non-fentanyl opioids	2
Methamphetamine	2
Cocaine	1
Cannabis	3
Multiple drugs of choice	1
Frequency of drug use
Daily or multiple times/day	10
Less than daily	3
Length of time using drugs
Less than 1 year	1
1–2 years	0
3–4 years	1
5–9 years	4
10–14 years	3
15 + years	1
Prefer not to say	3

Based on the data, the following themes were developed and are presented below: perspectives related to field-initiated buprenorphine, LBN, HIV/HCV testing; implementation preferences; approaches to care; additional services needed; and reducing law enforcement presence and visibility at overdose responses.

3.1 |. Perspectives related to field-initiated buprenorphine

Nearly all PWUD expressed positive perceptions about the possibility of receiving buprenorphine administered by EMS. Buprenorphine was perceived as generally easy to access in non-emergency settings by participants, with some PWUD suggesting that there were barriers to knowledge or access for other PWUD, but not themselves. The primary barrier described to buprenorphine utilisation was a person’s readiness to seek treatment. Interviewees were interested in being able to access buprenorphine through EMS for convenience, and because it could eliminate the knowledge and access barriers they described to treatment. They supported both telehealth and non-telehealth models of buprenorphine prescribing in the field and noted that after an overdose might be a moment when people are evaluating treatment possibilities and may want to access treatment. As one interviewee stated:

‘Yeah, that would be a good idea. The easier, the better when it comes to that opioid … we all want a quick fix, you want it done now, so that’s how your mentality should be, as far as that goes, like if you can make something fixed, do it that way. ‘Cause that’s gonna be the first go to for opioids. So that would be one dose.’—White woman, person who uses multiple drugs (ID #10)

However, some PWUD interviewed noted that it may be overwhelming to be offered medication for opioid use disorder right after an overdose, and one person brought up that it might feel “pushy”. They still thought it would be beneficial, but said that PWUD post-overdose would need to be approached with care. As one interviewee described:

‘Like where you just kind of got thrown into the situation, it was an accident you didn’t mean to OD. And then you got the stuff in you that’s making you feel horrible and then they’re trying to push the subs on you. Trying to get you to quit. And it’s just, it’s a lot to handle, it’d be good to, as that option to offer it in case some people decided that.’—White woman, person who uses opioids (non-fentanyl) (ID #12)

Although there were very few reservations expressed about this intervention overall, two interviewees did say that they personally would prefer to seek out the treatment themselves at a clinic, while still supporting EMS offering the service in the field for others. One interviewee felt that it was out of scope and incongruent with EMS roles and mission.

3.2 |. Perspectives related to leave-behind naloxone

Nearly unanimous support was offered for EMS distributing LBN. The PWUD we interviewed supported this intervention for three reasons: (i) because of the life-saving value of naloxone and the inability to predict who might need it and when; (ii) because of the importance of reviving someone from an overdose as soon as possible, ideally even before EMS arrives, and thus needing to have some on hand; and (iii) because of the potency and presence of fentanyl and the prevalence of overdose events. In describing the life-saving value of naloxone, one participant stated:

‘Look, Narcan saves lives, Narcan really save lives. That shit really works. So, as long as wherever there’s drug use …[…] They need to distribute.’—Hispanic man, person who uses fentanyl (ID # 1)

Interviewees also commented across the board that they felt that naloxone was easy to access and knew of places where they could obtain it if they wanted it, citing few barriers for themselves but hypothesising that other PWUD may not have the same ease of access. When asked if there were any issues they could foresee with EMS distributing LBN, largely there were no issues raised by the majority of participants. One participant wondered if PWUD might be able to sell it for profit, and another mentioned that they wouldn’t want to have to hear a “speech” if they were to receive it, and again the same person who felt buprenorphine was out of scope also brought up that LBN would be out of scope of practice and capacity for EMS who needs to be available to respond to acute emergencies.

3.3 |. Perspectives related to HIV/HCV testing

It was relatively uncommon for people to say that they wanted HIV/HCV testing and were not able to get it in our sample, so access to HIV/HCV testing was not present as a barrier in our dataset. Just one person expressed interest in being tested without knowing where they could access testing.

Overall, few PWUD cited access to HIV/HCV testing as a need for them personally or for people they knew. They were not particularly opposed to testing and said that they would have no objection to getting it from EMS “if they needed it” however, most did not perceive themselves to be at high risk or had been tested in the past and felt that was sufficient.

At the same time, most people said if testing was free and available alongside EMS services, they would probably use it out of convenience because they didn’t have a strong reason not to, and they anticipated other people would use it too. Fear of results was the main barrier cited when PWUD were asked about what barriers were present for accessing HIV and HCV testing in King County, and stigma was also offered as a barrier. In the voice of one of the PWUD interviewed:

‘Just like with me, somebody seeing me going out of the building or whatever. Stigma or whatever.’—Person who uses methamphetamine, gender and race/ethnicity not reported (ID#5)

3.4 |. Implementation preferences

For all three interventions discussed, we also asked people what kind of EMS team they would want delivering the services. Most people did not have a preference on who should deliver the interventions, but those that did have a preference wanted the services to be offered by a Mobile Integrated Healthcare team or a mobile medical team. As one interviewee said:

“It doesn’t matter. If it’s free, hey, let’s go.”—Hispanic man, person who uses fentanyl (ID # 1)

Alternatively, some felt that there might be less trust of EMS, especially police, and thought that peers or non-uniformed mobile medical providers would be preferred by PWUD because, as shared by an interviewee:

‘They seem to be more compassionate. They’re in it for … To help people, not just ‘cause it’s a paycheck.’—American Indian or Alaska Native man, person who uses methamphetamine (ID #6)

Interviewees strongly supported the idea of non-hospital or field-based post overdose interventions generally because of the ability to reach people who wouldn’t be comfortable accessing services in other institutions. As one interviewee described:

‘Honestly I think it’s good, ‘cause a lot of people, especially people in a drug culture, they don’t like to go into hospitals or any type of buildings period. And they’re used to the nature, used to the elements, I guess you can say, being outside. So if you know somebody’s offering some help and it’s not in a big official building, and there’s gonna be officials there and it’s anonymous, for the most part. Then yeah I think it’s a great thing.’—Man, person who uses crack/cocaine, race/ethnicity not reported (ID#7)

Implementation in “hot spots,” such as encampments or areas with a high frequency of drug-related calls was suggested as a good place to pilot these field-based EMS interventions.

For LBN specifically, there were many implementation suggestions offered, including having something in the kit to let the person receiving it know that someone cares about them (e.g., a kind note, a paper heart), information about the need to observe someone after administration in case the naloxone wears off, and things that could help with the intense withdrawal symptoms experienced after overdose reversal for someone with opioid use disorder (e.g., a cigarette, an acute dose of buprenorphine). Some people expressed that having LBN would make them less likely to call emergency services in the event of an overdose, if they were able to successfully revive the person themselves, whereas others noted that it wouldn’t change their behaviour but would simply allow a first dose to be administered sooner.

3.5 |. Approach to care

Participants described many past traumatic experiences with EMS and emergency department staff (who they often grouped together when describing overdose care). They shared a desire to be approached with compassion and care and emphasised the need to be listened to and not judged by EMS at the scene of an overdose. Interviewees wanted to be treated like “anyone else” by EMS not looked down on. One person described this as wanting EMS to “Show up promptly and with a kind attitude and then empathetically” in contrast to the way the person had been treated by EMS and emergency department staff in the past, which was:

‘Like I was scum, the minute they find out I used it it was like their whole demeanor changed. And it’s like that with hospitals too. They don’t give you the same care as a normal person, they don’t. Being a drug addict isn’t like, yeah, it was a choice in the beginning but in the end it’s not a choice. I don’t want to be hooked on a fentanyl, and I’m like taking the steps down and would bring myself off of it, but I deserve this same level of care as you.’—White, non-binary, person who uses fentanyl (ID #11)

They described a need to offer a calming presence and to instruct or help bystanders to be calm. Some interviewees noted that interactions between EMS and PWUD had improved recently. Participants cited negative experiences with care as a reason behind declining transport to the emergency department, further supporting field-based post-overdose interventions. One participant contrasted recent positive interactions they had with EMS to negative interactions with the emergency department:

‘Well, it seemed like they were much nicer and more understanding. It seemed like they … I don’t know, maybe they’ve just been through enough scenarios and situations where they maybe just kind of realise it’s not just what their idea is of who it can happen to, but they seem less judgmental and everything, where it’s not that way in the hospitals and clinics and stuff, so they seem much better to deal with, and that’s why I think a lot of people don’t want to go with them. Because you might be nice, but where you take me, they’re not gonna be … They’re very judgmental.’—White woman, person who uses opioids (non-fentanyl) (ID #12)

3.6 |. Additional services needed

Having a counsellor to offer post-overdose care and trauma counselling to the survivor and to any witnesses was suggested by many PWUD. Interviewees also said they would like to receive a follow-up call after an overdose event.

To build rapport and trust, some interviewees suggested that EMS could have community events to hand out supplies and to get to know PWUD in a non-emergency setting, or to teach CPR, first aid, or other skills to the general public. One interviewee also noted the importance of having providers who were racially and ethnically diverse, to increase patient comfort. Finally, having a diversion centre or sobering centre, or somewhere that people could get rest and respite was a recommendation made by those we interviewed. As one person said:

‘Maybe a place where they, a person can go in for a week even, and just rest, mentally and physically just rest. I think it would change a lot of things ‘cause for some of us just getting out of this rat race for just even a week is a miracle.’—Mixed race man, person who uses marijuana (ID #13)

3.7 |. Reducing the presence and visibility of law enforcement on scene

Interviewees spoke at length, unprompted, about some of the harms that can occur when law enforcement is present at the scene of an overdose. They described the effect this has on the person who has just survived the overdose, immediately making them think about the legal consequences they might face, and making them want to leave the scene, putting them at risk of repeat overdose and impacting their follow-up care. As one person said:

‘They might save you, but then you’re going to jail.’—Mixed race man, person who uses opioids (non-fentanyl) (ID#4)

Participants additionally described the isolation and potential harm that occurs when friends or family members leave the scene because of the presence of police and their own fear of arrest for outstanding warrants or drug paraphernalia. Finally, the potential for police presence to escalate the danger of a situation was brought up, where PWUD may become agitated or erratic because of the police being visible. Some interviewees noted that this fear of being arrested when calling for help during an overdose has lessened recently because of legislative changes. PWUD recognised that sometimes law enforcement needs to respond to overdose scenes when violence is occurring, but noted that this needed to be accompanied by an attempt to deescalate situations especially when people are experiencing an overload of amphetamines.

4 |. DISCUSSION

The participants interviewed in this study were highly supportive of more robust post overdose care being provided by EMS with the most support for LBN. Perspectives on field-initiated buprenorphine were slightly more mixed but largely favourable. Field-based HCV/HIV screening was not preferred. To our knowledge, PWUD perceptions of delivery of LBN, field-initiated buprenorphine and HIV/HCV testing in EMS settings were previously unknown, and we found support for two of these interventions. Stronger than the desire for a particular type of EMS provider to deliver the interventions was an expressed desire for people who are compassionate and empathetic, regardless of professional affiliation.

Notably, the people interviewed preferred not to have law enforcement respond due to expressed concerns about arrest of themself or someone who is with them. Our studies’ findings of PWUD perceptions of stigma and attitudes of EMS, police presence at overdose scene, post-overdose social and emotional care/trauma care needs all were elicited unprompted and suggest that these needs are present and a priority for PWUD post overdose.

There is robust literature describing overdose survivors’ transportation refusal and some other literature related to the needs and desires of PWUD for post-overdose care elicited in this study. Specifically, there are many documented barriers to PWUD dialling emergency services and extensive calls from PWUD to have an overdose response system that is not connected to the law enforcement dispatch system [47]. PWUD have cited intolerable withdrawal symptoms, anticipation of inadequate care upon arrival at the emergency department, and stigmatising treatment by both EMS and emergency department care providers as main reasons for refusal [48]. Some solutions to these concerns have been offered, including titrating naloxone to avoid harsh withdrawal symptoms, providing peer outreach or community paramedicine, addressing provider burnout to combat stigmatising treatment [48] and overdose receiving centres or alternative destinations to the ED [49]. PWUD report being more likely to accept EMS transport after overdose reversal if they are offered ease for withdrawal symptoms and treated with respect and empathy [48].

In our study, when asked about who should ideally implement the interventions, PWUD wanted Mobile Integrated Healthcare teams, non-uniformed staff, and generally people who would not be perceived as intimidating to deliver the interventions in the field, although they also cited EMS as appropriate implementers, especially of LBN. Similar suggestions arose in other studies, where PWUD supported sending a peer support specialist who would know what the patient was going through post overdose [47, 50–55]. This strategy is well-documented and has been operationalised in several of the post-overdose response models across the United States. For example, the Houston Emergency Opioid Engagement System (HEROES) program in Houston, Texas utilises a paramedic, a peer support specialist, a nurse practitioner who provides buprenorphine and a licensed chemical dependency counsellor who provides substance use counselling, to locate and engage opioid overdose survivors who decline emergency department transport [50, 51]. Programs such as EPICC (Engaging Patients in Care Coordination) in St. Louis, the RIMO (Recovery Initiation and Management After Overdose) intervention in Chicago, Project POINT (Planned Outreach, Intervention, Naloxone, and Treatment) in Indiana, and AnchorED (Anchor Recovery Center and Emergency Department) in Rhode Island also leverage the lived experience of peer support specialist within their programs [52–55].

Overdose response teams could be additionally enhanced by also offering more support than a typical referral process would provide, as our participants requested, and programs have been developed to include active follow-up with patients after the initial intervention and referrals [47]. PWUD have asked that post-overdose interventions be flexible enough to allow people to talk about their “real problems”, centred on patients’ needs and not exclusively focused on treatment [47] which is aligned with the cautions voiced by our participants about respecting patients’ readiness to seek treatment and ensuring offers of field-initiated buprenorphine are not forceful.

4.1 |. Limitations

Our sample of PWUD was selected by convenience and should not be considered representative of other PWUD perspectives in other geographic regions or contexts. Specifically, we recruited from places where people were able to access some of the harm reduction and health care services about which we were asking, so they may not have had access barriers to these services that are present for other PWUD. Further, we do not have data about our participants (e.g., experience with intravenous drug use or sex work) that may have been helpful contextually for understanding participant knowledge of and desire for HIV/HCV testing. However, we still found a high degree of support and usefulness for EMS distribution of LBN and buprenorphine, despite a lack of access barriers. Another limitation pertains to our data about acceptability and usefulness of interventions, which produced implementation findings that are highly regional. Our sample came from south, central, and north Seattle, where the harm reduction interventions we asked about may be more feasible to implement and more well-received by the general public than, for example, in the more rural surrounding regions. Still, with this targeted data collection approach we produced specific and actionable recommendations that can be applied in the local context, and we encourage others to replicate this work to extend findings to new contexts. In addition, to prevent re-traumatisation, the research team asked which drugs participants used most frequently, instead of explicitly asking about opioid use. While there is a chance not all participants in this study had used opioids, given that the study recruitment called for people who had experience with opioids, and based on what participants described in interviews, the research team feels certain that all of the study participants used opioids at some point in their lives. Similarly, to reduce feelings of re-traumatisation, the team did not ask specifically whether the overdose experience participants described were their own experience or an overdose they had witnessed someone else having; although the process of reviewing and coding transcripts provided the research team with a high level of certainty that all of the participants had experienced an overdose themselves.

4.2 |. Unanswered questions

Future research is needed to better understand what models of peer support post-overdose are most effective in supporting PWUD and establishing connections to care. Research into these models should investigate both the interventions offered and the personnel responding, as the demeanour of the person responding was highlighted by participants as crucial. Further, if these interventions are offered at a large scale in EMS systems, research is needed both on how to implement post-overdose interventions in a way that is not perceived as coercive and is aligned with preferences of PWUD and to test their ability to improve patient outcomes at a population level. Finally, overdose is not evenly distributed in the population, but is far more likely experienced by those impacted by systemic racism, those facing socioeconomic marginalisation, and those who are experiencing houselessness. It is imperative that we test the ability of these interventions to respond to the needs of these groups and to test their ability to eliminate disparities in overdose.

5 |. CONCLUSION

The policy and practice implications for our study point to the need to evolve post overdose care by EMS. First, PWUD endorse both LBN and field-initiated buprenorphine being offered by EMS. Second, our study supports training for EMS providers to reduce stigma and increase trauma-informed approached for PWUD post overdose, as has been recommended by the Metropolitan Municipalities EMS Medical Directors Alliance [56]. This study also supports the establishment of specialty overdose response team that include peers and non-uniformed staff who can offer field interventions and connect patients to care after overdose response. These connections to care would not need to involve law enforcement and should be done with a compassionate, non-judgmental approach. Several other municipalities have piloted or implemented such teams with favourable early results [50, 51]. Finally, PWUD, our study and others have called for alternatives to the emergency department post-overdose [48, 49] and post-overdose stabilisation facilities should be established locally to improve outcomes and provide diversion from the ED. These recommendations and others are being considered by EMS in King County and should be considered by other jurisdictions looking for evidence-informed ways to respond to the overdose crisis that are informed by PWUD.

Key Point Summary.

• People who use drugs supported post overdose care by emergency medical services, including leave-behind naloxone and buprenorphine.

• People who use drugs preferred not to have law enforcement at the scene post overdose.

• People who use drugs preferred that post overdose interventions be delivered in a compassionate and non-coercive manner.

APPENDIX A: INTERVIEW GUIDE QUESTIONS

First responder encounters
Question	Probes
Can you tell me about your most recent interaction with a first responder (fire fighter, police or paramedic)?	• What led to that situation with the first responder? • What have your interactions been like with first responders during an overdose, either for yourself or when you’ve been a bystander? • How satisfied did you feel with the outcome of that interaction? • Did you receive any referrals to other supports or services from the first responder you interacted with? • [If they don’t already mention it] How long ago was that interaction?
What would a good interaction look like between a first responder and someone experiencing an overdose?	• How should a first responder approach the people at an overdose response call? • What would be most helpful for you when you are met by someone who is responding to an overdose or another drug-related emergency? • Would there be any other supports or services that would be helpful to receive when a first responder responds to an overdose or other drug-related call?
Have you ever had interactions with mobile integrated health team or a co-responder team consisting of a first responder paired with a mental health professional like a nurse or social worker? What was that interaction like?	• What do you think about receiving services from teams like these, as opposed to traditional first responders? • Are there services for substance use that you think should definitely be available through mobile clinic or co-responder programs rather than first responders? Why?
Experiences with opioid-related services
Question	Probes
Have you ever gotten naloxone, also known as Narcan, to take home with you or carry on you?	[If never received], • Can you tell me why you haven’t accessed naloxone? • Did you have any issues or challenges with getting naloxone when you’ve wanted to get some? What kinds of issues? • Is take-home naloxone easy to access, in your opinion? What makes it easy/hard to access? • If naloxone was offered to you for free by a first responder, to take home or carry with you, would you take it? Why or why not? [If received], • Do you have it right now? If so, where did you get the naloxone from? • Is take-home naloxone easy to access, in your opinion? What makes it easy/hard to access? • If naloxone was offered to you for free by a first responder, to take home or carry with you, would you take it? Why or why not?
How do you feel about first responders handing out naloxone to patients or bystanders when they respond to an overdose? Is this something you or people you know would want?	• How should first responders offer these kits to people? What about their approach would make you more or less likely to want to take a naloxone kit? • What should be included in these kits? • Do you think these services should be offered by first responders? What might be some problems with first responders offering this service? • Do you have a preference for what kinds of first responders or mobile clinic staff you’d get naloxone from? Why? • How does (or would) having naloxone with you affect your likelihood of calling 9–1-1 in an overdose event?
Experiences with opioid-related services
Question	Probes
Buprenorphine, also known as Suboxone, is a medication used to treat opioid use disorder. Can you tell me about any experiences you may have had receiving buprenorphine?	[If never accessed]: • Can you tell me why you haven’t received this medication before? • How easy is buprenorphine easy to access, in your opinion? • How do other people you know (who use drugs) feel about buprenorphine? • If the option to start buprenorphine treatment was available and free alongside first responder services, would you have wanted to start it that way? Why or why not? [If have accessed]: • Do you currently have buprenorphine? • Where did you get the buprenorphine/Suboxone from? • Did you have any issues or challenges with obtaining buprenorphine or Suboxone? What kinds of issues? • How easy is buprenorphine easy to access, in your opinion? • How do other people you know (who use drugs) feel about buprenorphine? • If the option to start buprenorphine treatment was available and free alongside first responder services, would you have wanted to start it that way? Why or why not?
Between different kinds of first responders and mobile clinic staff, who would you prefer to receive buprenorphine from?	• What do you think would be good about receiving buprenorphine from first responders like firefighters or paramedics? • What about from mobile clinics? • What sorts of challenges would you expect to encounter receiving a medication this way? • What would you think about participating in a telemedicine visit with a provider who could prescribe buprenorphine, facilitated by a first responder or mobile clinic staff member?
Experiences with other medical services
Question	Probes
Can you tell me what you know about testing for HIV and hepatitis C?	• Have you ever wanted to be tested for HIV or Hep C but haven’t been able to? If so, what stopped you from getting tested? • What do you think some of the barriers are to accessing testing for HIV or Hep C? • Can you tell me anything else about why you think people who use drugs may not want to get tested?
If HIV or Hep C testing was available and free in first responder services would you use it? Why or why not?	• Do you think other people would use these testing services from first responders? • Between different kinds of first responders and mobile clinic staff, who would you prefer to receive testing from? • If first responders or mobile clinic staff are engaging with people out in the community, what do you think they can do that would help people feel more comfortable and willing to get tested?
If you needed treatment for Hep C and linkage to Hep C treatment were free and available alongside first responder services, would you use it? Why or why not?	• Have you ever accessed treatment for HCV? If yes, how did you start that treatment process? If not, why not? • What sorts of challenges would you expect people would encounter receiving treatment this way?
Do you think it would be helpful for first responders to provide access to safer use supplies, like syringes, pipes, or fentanyl testing strips? Why or why not?	• What sorts of challenges would you expect to encounter receiving safer use supplies like this? • Is there anything I didn’t mention that you think should be included with safer use supplies?
Other needs and preferences
Question	Probes
First responder services have gone through some changes recently. Have you noticed any ways that your experience interacting with first responders has changed over time?	• What kinds of differences have you noticed (if any)? • When did you start to notice these changes?
Are there any other services (other than the ones we asked you about) that you think would be important to have offered by first responder to better serve people who use drugs?	• Are there different things that are more important to you than the services we mentioned today? • Are there other services that you have trouble accessing?

Finally, we would like to ask you some questions about your identity so that we can understand how representative our interviews are of people who use drugs.

A.1. | Demographic questions

1. What is your gender identity? _______________________________________________________________________

2. What term would you use to describe your race?________________________________________________________

3. What is your age?_________________________________________________________________________________

APPENDIX B: LIST OF CODES AND CORRESPONDING CFIR CONSTRUCT

Code category	Parent code	Child code
Outer setting/implementation context	Barriers to care	Budget for interventions Lack of access to care Lack of stability in care Negative feelings about first responders Stigma
	Facilitators to care	Positive feelings about first responder services Low/No barrier access Non-stigmatising environment and rapport building Services brought to PWUD Trauma-informed care Effective first responder communication style
Intervention characteristics	N/A	Buprenorphine HIV/HCV Testing Leave behind naloxone (LBN)
Characteristics of individuals	Perceptions of buprenorphine	Ambivalence toward buprenorphine Interested in buprenorphine Not interested in buprenorphine
	Perceptions of HIV/HCV testing	Ambivalence toward HIV/HCV testing Interested in HIV/HCV testing Not interested in HIV/HCV testing
	Perceptions of LBN	Ambivalence toward LBN Interested in LBN Not interested in LBN
Inner setting	N/A	Characteristics of personal drug use Experiences with overdose Perceptions of first responder roles Perceptions of police Scope of first responder services and mission
Process	Implementation recommendations	Buprenorphine HIV/HCV Testing LBN
	Implementers	Paramedics should provide intervention Firefighters should provide intervention Mobile/outreach clinic should provide intervention Paramedics should not provide intervention Firefighters should not provide intervention Mobile/outreach clinic should not provide intervention Police should not provide intervention Peers should provide intervention