Skip to main content
PMC home page
NIHPA Author Manuscripts logoLink to NIHPA Author Manuscripts
. Author manuscript; available in PMC: 2016 Aug 1.
Published in final edited form as: Drug Alcohol Depend. 2015 May 27;153:215–220. doi: 10.1016/j.drugalcdep.2015.05.026

Association between non-fatal opioid overdose and encounters with healthcare and criminal justice systems: Identifying opportunities for intervention

Karla D Wagner a, Lin Liu b, Peter J Davidson c, Jazmine Cuevas-Mota c, Richard F Armenta c, Richard S Garfein c
PMCID: PMC4512661  NIHMSID: NIHMS705014  PMID: 26091751

Abstract

Background

Accidental overdose, driven largely by opioids, is a leading cause of death among people who inject drugs (PWIDs). We conducted secondary analysis of data from a cohort of PWIDs to identify venues where high-risk PWID could be targeted by overdose education/naloxone distribution (OEND) programs.

Methods

573 PWIDs completed a quantitative survey between June, 2012 and January, 2014, which was analyzed using multivariable logistic regression. The dependent variable was a dichotomous indicator of experiencing a heroin/opioid-related overdose in the past six months. Independent variables included: demographics, drug use behavior, and encounters with two venues – the health care and criminal justice systems – that could serve as potential venues for OEND programs.

Results

Almost half (41.5%) reported ever experiencing a heroin/opioid overdose, and 45 (7.9%) reported experiencing at least one heroin/opioid overdose in the past six months. In the final multivariable model, receiving care in a hospital in the past six months (Adjusted Odds Ratio [AdjOR] 4.08, 95% Confidence Interval [C.I.] 2.07 -- 8.04, p<0.001) and being arrested for drug possession in the past six months (AdjOR 5.17, 95% C.I. 2.37 – 11.24, p<0.001) were associated with experiencing an opioid overdose in the past six months.

Conclusions

Identifying venues outside of those that traditionally target services to PWIDs (i.e., syringe exchange programs) will be critical to implementing OEND interventions at a scale sufficient to address the growing epidemic of heroin/opioid related deaths. Clinical settings, such as hospitals, and drug-related encounters with law enforcement officers are promising venues for the expansion of OEND programs.

Keywords: opioids, overdose, overdose prevention, people who inject drugs, naloxone

1. INTRODUCTION

Unintentional overdose death is now the leading cause of injury death in the United States (Centers for Disease Control and Prevention (CDC), 2014), and has been the leading cause of death among people who inject drugs (PWIDs) for many years (Tyndall et al., 2001). Prescription opioids and heroin account for a large and growing share of drugs involved in overdose deaths in the U.S. (Chen et al., 2014; Rudd et al., 2014). Risk factors for opioid overdose have been well-established, and include factors such as: loss of tolerance after periods of abstinence, concomitant use of other drugs (especially alcohol and other CNS depressants, but also stimulants such as cocaine), frequency of drug use, and characteristics of the drug such as purity and presence of adulterants (Coffin et al., 2003; Darke and Hall, 2003; Warner-Smith et al., 2001). Drug injection also confers a significantly elevated risk of overdose compared to other routes of administration (Brugal et al., 2002; Darke and Hall, 2003).

Naloxone hydrochloride is an opioid antagonist that specifically reverses the effects of opioids and restores breathing in an individual experiencing an opioid overdose (Baca and Grant, 2005). Overdose education and naloxone distribution (OEND) programs identify drug users at risk for opioid overdose, provide education about risk factors and appropriate response techniques, and prescribe naloxone to program participants (Clark et al., 2014; Maxwell et al., 2006). With a few exceptions, the majority of OEND programs in the US have been implemented by syringe exchange programs or other community-based organizations that primarily serve PWIDs (CDC, 2012; Clark et al., 2014; Doe-Simkins et al., 2009; Enteen et al., 2010; Wagner et al., 2010).

Given the breadth and scope of the opioid overdose epidemic, and the fact that not all PWIDs in the U.S. have access to syringe exchange programs, there is a need to identify other venues where high-risk PWID can be identified and provided with OEND programs. Two potential venues are health care and criminal justice settings (CDC, 2012). Physicians in primary care, pain management, hospital emergency departments, and other clinical settings can deliver overdose prevention training and prescribe naloxone to patients at risk of opioid overdose (Beletsky et al., 2007; Burris et al., 2001; Mayet et al., 2011) though the practice is relatively uncommon, particularly among those who are not familiar or comfortable with the health concerns of people who use drugs (Beletsky et al., 2007). The criminal justice system is another venue where drug users at high risk for opioid overdose could be targeted for OEND interventions, in light of calls for the criminal justice system to align with public health goals (Silverman et al., 2012) and increased attention to the role that law enforcement officers can play in responding to the epidemic of opioid overdose death (Banta-Green et al., 2013; Davis et al., 2014; Green et al., 2013b; Ray et al., 2014).

In the current study, we conducted secondary analysis of data collected from a cohort of PWID recruited in San Diego, California to identify venues where high-risk PWID could be targeted by OEND interventions. Because individuals who have overdosed previously are at increased risk for dying from a subsequent overdose (Stoove et al., 2009), we identified participants who reported at least one opioid overdose in the past six months. We then examined a set of independent variables representing contacts with two primary venues –health care and criminal justice settings – that could be used to deliver OEND interventions for PWID at high risk for fatal opioid overdose.

2. METHODS

2.1 Recruitment

Data for this secondary analysis were drawn from the baseline visit of an ongoing longitudinal cohort study designed to investigate health outcomes among PWIDs in San Diego, California. A full description of the study methods is available elsewhere (Robertson et al., 2014). Briefly, eligibility criteria for the cohort included: age ≥18 years, injection of illicit drugs within the past 30 days (confirmed by observation of injection stigmata or other physical evidence of injection), ability to speak English or Spanish, San Diego resident with no plans to move for two years, and not currently participating in any intervention study. Recruitment was conducted using street- and venue-based outreach, targeted advertising (e.g., ads in local newspapers, flyers), websites, and peer referrals. Potentially eligible participants completed a brief screening interview. Individuals determined to be eligible for the study were invited to participate and those who agreed provided written informed consent. The Institutional Review Board of the University of California, San Diego approved all study procedures.

2.2 Data collection

Data were collected using an interviewer-administered questionnaire via Computer Assisted Personal Interview (CAPI) software installed on a laptop computer. The questionnaire included standard demographic items (e.g., age, sex, race/ethnicity, homelessness status). The dependent variable of interest – experiencing a heroin/opioid overdose in the past six months –was measured using a single item that asked participants “In the past six months, how many times have you overdosed on heroin or other opiates?” Overdose was defined as “times when you took so much drug that you lost consciousness, stopped breathing, and something had to be done if you were going to come back.” Participants who reported experiencing at least one heroin/opioid overdose in the past six months were also asked a series of questions about the most recent overdose event, including the drugs they used in the 12 hours prior to the overdose, whether and for what reason they had stopped using drugs for three or more days prior to the overdose, and what actions were taken by others at the overdose event.

Throughout the questionnaire, a number of sections assessed participants’ encounters with healthcare and criminal justice systems. In the section on healthcare access, participants were asked whether they had received care or accessed services in any of the following venues in the past six months: hospital, emergency department (ED), outpatient clinic, or local syringe exchange program (1=yes, 0=no). In a separate section, participants were asked about their encounters with the criminal justice system in the past six months, including whether or not they: had been arrested for drug possession or carrying syringes, had police confiscate their syringes, were on parole or probation, or had any outstanding warrants for their arrest (1= yes, 0=no). Participants were also asked whether their experiences with police: caused them to hurry or rush an injection, affected where they buy or use drugs, or affected their access to new syringes (1=yes, 0=no). Finally, participants were asked to respond to the question, “How fearful are you that police are going to arrest you or interfere with your drug use?” on a 3-point scale (0=not at all fearful, 1=somewhat fearful, 2=very fearful).

2.3 Analysis

The dependent variable was a binary indicator of whether or not participants reported experiencing at least one heroin/opioid overdose in the past six months. We examined associations with three categories of independent variables: demographics, health care system encounters, and criminal justice system encounters. All variables of interest were summarized by descriptive statistics including frequencies and measures of central tendency and dispersion. We used Chi-square, Fisher’s exact, and Wilcoxon rank sum tests to examine bivariate associations between dependent and independent variables. Variables that were statistically significant at p≤0.05 in the bivariate analysis were included in a multivariable logistic regression model. The logistic regression model was trimmed manually in a backwards, stepwise fashion in which the variable with the largest p-value was removed at each step until the most parsimonious final model was achieved, including only those variables significant at p<0.05.

3. RESULTS

The cohort consisted of 573 PWIDs recruited between June 2012 and January 2014. Almost half (n=238; 41.5%) reported ever experiencing a heroin/opioid overdose, and 45 (7.9%) reported experiencing at least one heroin/opioid overdose in the past six months. The median number of overdoses experienced by those 45 individuals in the past six months was one (interquartile range = 1–2; max = 10). Table 1 describes the circumstances of the most recent heroin/opioid overdose. Participants reported consuming several different drugs in the 12 hours prior to the overdose; the most commonly consumed drugs were heroin (73.8%), methamphetamine (28.6%), and alcohol (16.7%). Nearly one-quarter reported that they had stopped using drugs for three or more days prior to the overdose. Emergency services (i.e., 911) was called in 51% of the overdose events. In slightly less than half of the events (46.7%) participants were taken to a clinic or hospital. Participants reported receiving naloxone from bystanders in 16.3% of cases. Six (14.0%) participants reported that a bystander gave them Suboxone in an attempt to reverse the overdose. Suboxone is a medication used to treat opioid dependency, which contains a combination of buprenorphine (a partial opioid agonist) and naloxone (an opioid antagonist) and can precipitate opioid withdrawal (Julien, 2005).

Table 1.

Descriptive characteristics of most recent heroin/opioid overdose (N=45)

n %
Drug(s) used in the 12 hours before the last overdose (check all that apply; n=42)
 Heroin by itself 31 73.8
 Methamphetamine 12 28.6
 Alcohol 7 16.7
 Tranquilizers (rivotril, diazepam, valium, Ativan, or restoril) 5 11.9
 Marijuana 4 9.5
 Other prescription opioids (Vicodin, Darvon, Percocet) 3 7.1
 Crack by itself 1 2.4
 Cocaine by itself 0 0
 Heroin and cocaine together 0 0
 Methamphetamine and heroin 0 0
 OxyContin 0 0
Stopped using drugs for 3 or more days before the most recent overdose 11 24.4
 Why stopped for 3 or more days? (n=11)
  Was in jail/prison 3 27.3
  Was in detox/drug treatment 1 9.1
  Just wanted to 4 36.4
  Other 3 27.3
Emergency services were called for last overdose 23 51.1
Taken to clinic or hospital 21 46.7
Someone other than paramedic or medical professional gave you naloxone to treat overdose (n=43) 7 16.3
Anyone gave you Suboxone (R) to treat overdose (n=43) 6 14.0
Open in a new tab

Table 2 shows the results of bivariate comparisons between those who reported experiencing a heroin/overdose in the past six months and those who did not. Participants who had experienced an overdose were younger (mean: 38 years vs. 44 years, p=0.01) and more likely to be homeless (77.8% vs. 59.7%, p=0.02) compared to those who had not overdosed in the past six months. There were no statistically significant differences in sex (male vs. all others), or race/ethnicity.

Table 2.

Factors associated with reporting a non-fatal heroin/opioid overdose in the past six months (N=573)

≥ 1 overdose in the past six months (n=45; 7.9% ) No overdoses in the past six months (n=528; 92.1%)
n % n % p-value
Demographics
 Age (mean, SD) 38 12 44 12 0.01
 Male 29 64.4 388 73.6 0.22
 Race/ethnicity 0.46
  White 26 57.8 266 50.4
  Hispanic/Latino 14 31.1 164 31.1
  Other 5 11.1 98 18.6
 Homeless past six months 35 77.8 315 59.7 0.02
Health care system encounters (past six months)
 Received care in hospital 18 40.0 87 16.5 <0.001
  Median number of times hospitalized (IQR; n=105) 2 1,3 1 1, 2 0.11
 Received care in ED 24 53.3 176 33.5 0.01
  Median number of times visited ED (IQR; n=198) 2 1, 2.3 2 1, 3 0.46
 Received care in outpatient clinic 14 31.1 153 29.1 0.74
  Median number of times visited outpatient clinic (IQR; n=167) 2 2, 5 3 1, 6 0.61
 Used local SEP 17 37.8 219 41.5 0.75
Criminal justice system encounters (past six months)
 Arrested 19 43.2 135 25.7 0.02
 Arrested for drug possession 12 27.3 38 7.3 <0.001
 Arrested for carrying unused syringes 2 4.5 10 1.9 0.24
 Arrested for carrying used syringes 3 6.8 16 3 0.18
 Police have confiscated syringes 7 16.3 45 8.5 0.10
 Police presence caused hurried or rushed injection 18 40.9 133 25.3 0.03
 Police presence has affected location of drug purchases 19 43.2 210 39.9 0.75
 Police presence has affected location of drug use 19 43.2 200 38.0 0.52
 Experience with police has affected access to new syringes 7 15.9 44 8.4 0.10
 Somewhat/very fearful that police are going to arrest or interfere with drug use (vs. not at all fearful) 32 72.7 308 58.7 0.08
 Currently on parole or probation 17 38.6 148 28.2 0.17
 Currently have outstanding warrants for arrest 4 9.3 27 5.2 0.29
Open in a new tab

Note: statistical comparisons were made using Chi-square test or Fisher’s exact test for frequencies, and Student’s T test and Wilcoxon Rank Sums test for means/medians.

In terms of healthcare system encounters, a higher proportion of participants who overdosed in the past six months reported that they had received care in a hospital (40.0% vs. 16.5%, p<0.001) or an ED (53.3% vs. 33.5%, p=0.01) in the past six months, compared to those who had not overdosed. There were no differences in frequency of encounters with outpatient health clinics or syringe exchange programs.

In terms of law enforcement encounters, a higher proportion of participants who overdosed in the past six months reported that they had been arrested for any reason in the past six months (43.2% vs. 25.7%, p=0.02), had been arrested for drug possession in the past six months (27.3% vs. 7.3%, p<0.001), and had their syringes confiscated by police in the past six months (16.3% vs. 8.5%, p=0.10). Participants who overdosed in the past six months also more frequently reported that police presence caused them to hurry or rush an injection (40.9% vs. 25.3%, p=0.03) and that their experience with police has affected their access to new syringes (15.9% vs. 8.4%, p=0.10). Finally, a higher proportion of those who experienced an overdose in the past six months reported that they were somewhat or very fearful that police would arrest them or interfere with their drug use (72.7% vs. 58.7%, p=0.08). There were no statistically significant differences in frequency of arrest for other reasons (e.g., carrying new or used syringes), parole/probation status, or existence of outstanding warrants.

In the final multivariate model controlling for age, two venue-based factors remained independently associated with reporting a non-fatal heroin/opioid overdose in the past six months (Table 3). The odds of reporting a recent overdose were increased by three times among those who had received care in a hospital in the past six months (Adjusted Odds Ratio [AdjOR] 4.08, 95% Confidence Interval [C.I.] 2.07 – 8.04, p<0.001). Using Fisher’s Exact Test we did not find a statistically significant association between receiving care in a hospital in the past six months for any reason and being taken to a clinic or hospital at the time of the most recent overdose (p=0.14). Sixty-one percent of individuals who received care in a hospital or clinic in the past six months also reported being taken to a clinic or hospital at the time of their last overdose. The odds of reporting a recent overdose were increased by four times among those who had been arrested for drug possession in the past six months (AdjOR 5.17, 95% C.I. 2.37 – 11.24, p<0.001).

Table 3.

Factors independently associated with reporting a non-fatal heroin/opioid overdose in the past six months (n=573)

Adjusted Odds Ratio 95% Confidence Interval p-value
Age (per 5 year increase) 0.81 0.71, 0.94 0.004
Received care in a hospital last six months 4.08 2.07, 8.04 <0.001
Arrested for drug possession past six months 5.17 2.37, 11.24 <0.001
Open in a new tab

4. DISCUSSION

We found that nearly half of this sample of PWIDs had experienced at least one non-fatal overdose in their lifetime, consistent with other research (Bradvik et al., 2007; Latkin et al., 2004; Philbin et al., 2008; Pollini et al., 2006; Seal et al., 2001; Sergeev et al., 2003; Sherman et al., 2007). Further, we found that 8% of the sample had experienced a non-fatal overdose in the previous six months. Our findings regarding the characteristics of the overdose events were consistent with the literature on risk factors for opioid overdose (e.g., Darke and Hall, 2003): participants reported using a wide variety of drugs prior to the overdose event and nearly one-quarter reported that the overdose occurred after a period of abstinence.

We investigated associations between heroin/opioid overdose and encounters with two primary venues where PWIDs come into contact with entities that could provide OEND programs: the health care and criminal justice systems. Clinical settings such as hospitals are potential venues for OEND programs, and our findings suggest that PWID at the highest risk for dying from an opioid overdose do access care from hospitals with some frequency. Overall, nearly one in five of our participants had received care in a hospital in the past six months, and those who had received care in a hospital were more likely to report experiencing a recent overdose. While it makes sense that some degree of correlation between overdose and hospitalization should exist, we did not detect a statistically significant association between receiving care in a hospital for any reason and begin taken to a clinic or hospital after the most recent overdose event. It is important to note that less than half of those who had overdosed in the past six months said that they were taken to the hospital after their most recent overdose. Therefore, we suggest that PWIDs are accessing health care from hospitals for both overdose and non-overdose related reasons and, whether the visit is due to an acute overdose event or for other health care needs, the provision of OEND programs through hospitals can reach PWIDs who are at high risk for overdose-related morbidity. Interestingly, receiving care in an outpatient clinic was not associated with reporting a recent overdose. This may be because high-risk PWIDs are less likely to be insured, and therefore less likely to receive care in a clinic compared to a hospital or ED setting. While some research shows support by clinicians for providing naloxone to people at risk for opioid overdose (Green et al., 2013a), both attitudinal and procedural barriers remain, and clinicians will need training and organizational support for integrating OEND into existing protocols.

Participants who had been arrested for drug possession were significantly more likely to report experiencing a recent overdose. Though this was the only criminal justice system variable retained in the final regression model, bivariate analysis showed that a larger proportion of participants who had recently overdosed reported interacting with the criminal justice system in a number of other ways, including having syringes confiscated, hurrying or rushing injections due to police presence, and fearing that police presence will interfere with their drug use. Research has described the “bolus effect”, in which a rapid administration of the drug causes a higher blood concentration of the drug than would otherwise be experienced, leading to more severe respiratory depression (Davidson, 1999). Though the aim of our current analysis was not to identify risk factors for overdose, it could be that rushed injections due to fear of police interference stimulate such an effect, thereby increasing the risk for overdose.

Research on HIV and other health risks suggests that there is room for law enforcement and public health to work together to improve health outcomes among PWIDs (Beletsky et al., 2011; Bluthenthal et al., 1999a, 1999b; Martinez et al., 2007; Wagner et al., 2013b). Recently, communities have begun enlisting law enforcement officers to assist in the prevention of fatal overdose by training them in overdose prevention and naloxone administration (Banta-Green et al., 2013). In 2014, then Attorney General Eric Holder urged federal law enforcement agencies to train their personnel how to respond to opioid overdose and to equip them with naloxone (Office of the Attorney General, 2014). It is possible that training law enforcement officers in overdose response could save lives through naloxone administration, though no rigorous evaluation studies of this intervention exist to date. Nonetheless, our findings also suggest that interactions with law enforcement officers could serve as opportunities for PWIDs to access OEND services through appropriate referrals. When drug users are arrested for drug possession or other offenses, providing referrals to evidence-based drug treatment, syringe access services, and OEND programs should all be part of a comprehensive approach to reducing drug-related harms.

We found that 911 was called in only 51% of recent overdose events. Other research has shown that PWIDs are afraid to call 911 for fear of police response and possible arrest (Davidson et al., 2002). However, the effect of this fear on calling 911 might be modified based on individuals’ experiences with the police. In a study among PWIDs in Baltimore, fear of arrest was associated with increased likelihood of calling 911 among those who had previous experience with police, and was negatively associated with calling 911 among those with no previous experience with police (Tobin et al., 2005). Having positive experiences with law enforcement officers at the scene of an overdose (e.g., receipt of medical assistance and appropriate referrals) could help minimize fears and increase the likelihood that PWIDs will seek emergency medical assistance in the event of future overdoses.

Despite recent advancements in the reach and scope of OEND programs, to our knowledge at the time of this study (2012–2014) there were no organized OEND programs distributing naloxone to PWIDs in San Diego. Therefore, it is notable that seven participants reported that someone other than a medical professional administered naloxone at their last overdose event. This could reflect dissemination of OEND information and naloxone through drug user networks in the region (Wagner et al., 2013a), particularly since OEND programs have been operating in nearby cities since at least 2006 (Wagner et al., 2010). It is also notable that six participants reported being given Suboxone by someone attempting to treat their overdose. Other cases of sublingual and intravenous administration of Suboxone by laypeople to treat overdose have been reported (Welsh et al., 2008; Yokell et al., 2012). However, Suboxone is a medication used for the treatment of opioid dependence and is not recommended for the treatment of overdose. Therefore, current recommendations to call 911 and administer rescue breathing and naloxone are still recommended as best practices to respond to opioid overdose (Nielsen and Lintzeris, 2008; Yokell et al., 2012).

4.1 Limitations

Our findings should be considered in light of some limitations. Data were all obtained via self-report by the individual who experienced the overdose; therefore, the descriptions of the circumstances of the last overdose are likely affected by recall bias. Individuals who experienced an overdose might not accurately recall or be aware of the details of the event. Recall bias may also affect responses to the independent variables, including the type and frequency of interactions with healthcare and criminal justice systems. Though we provided a definition of overdose to assist participants in determining whether the event was truly an overdose, misclassification of the dependent variable was possible. For example, participants might have described events that were not truly an overdose (e.g., simply over-consumption), or an overdose event that was not caused by heroin/opioids. This is a limitation of most self-report data on non-fatal overdose that does not include a clinical assessment, though the inclusion of consistent definitions and training of interviewers may help to reduce this bias. Because we conducted a secondary analysis of data collected by an existing and ongoing study, there may be other variables representing important venues for providing OEND programs that were not available for this analysis. For example, we did not have data on recent utilization of substance abuse treatment – another important venue where PWIDs at risk for overdose death are likely to be encountered. Finally, as with all non-experimental, observational designs, our findings cannot be used to determine causality or order of precedence.

4.2 Conclusion

Between 1999 and 2011, the rate of overdose deaths involving prescription opioids in the United States nearly quadrupled from 1.4 per 100,000 to 5.4 per 100,000, and heroin-related deaths increased 45% (Chen et al., 2014; Rudd et al., 2014). While these trends have focused attention on the prominent role played by prescription opioids, more recent data suggest that deaths related to prescription opioids may be declining, while heroin overdose deaths continue to climb (Rudd et al., 2014). While the authors found no statistical correlation between the decreasing deaths involving prescription opioids and increasing heroin-involved deaths (Rudd et al., 2014), other research has demonstrated a high probability that individuals who initiate opioid use with prescription opioids transition to heroin use when prescription opioids become too expensive or unavailable (Pollini et al., 2011). For many opioid users, transition to injection as the preferred route of administration soon follows (Lankenau et al., 2012; Young and Havens, 2012), and injection is an independent risk factor for overdose (Darke and Hall, 2003; Davidson, 1999). Therefore, an ongoing focus on prevention of overdose death among PWIDs is warranted. Identifying venues outside of those that traditionally target services to PWIDs (i.e., syringe exchange programs) will be critical to implementing OEND interventions at a scale sufficient to address the growing epidemic of heroin/opioid related deaths. Clinical settings such as hospitals and drug-related encounters with law enforcement officers are promising venues for the expansion of OEND programs.

Highlights.

  • Eight percent of participants had a heroin/opioid overdose in the past six months

  • Overdose was associated with hospital care and arrest for drug possession

  • Criminal justice and clinical settings should address overdose death prevention

Acknowledgments

Role of Funding Sources

This research was supported by National Institute on Drug Abuse Grants: K01DA031031, R01DA031074 and K01DA032443. NIDA had no further role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the paper for publication.

The authors gratefully acknowledge the contributions of study participants and staff.

Footnotes

Contributors

Author Wagner designed the statistical analysis and wrote the manuscript. Author Lin conducted the statistical analysis. Authors Davidson, Cuevas-Mota, Armenta and Garfein provided input on the statistical analysis and feedback and comments on the manuscript. All authors contributed to and have approved the final manuscript.

Conflict of Interest

All authors declare that they have no conflicts of interest.

Publisher's Disclaimer: This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final citable form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.

References

  1. Baca CT, Grant KJ. Take-home naloxone to reduce heroin death. Addiction. 2005;100:1823–1831. doi: 10.1111/j.1360-0443.2005.01259.x. [DOI] [PubMed] [Google Scholar]
  2. Banta-Green CJ, Beletsky L, Schoeppe JA, Coffin PO, Kuszler PC. Police officers’ and paramedics’ experiences with overdose and their knowledge and opinions of Washington State’s drug overdose-naloxone-Good Samaritan law. J Urban Health. 2013;90:1102–1111. doi: 10.1007/s11524-013-9814-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
  3. Beletsky L, Agrawal A, Moreau B, Kumar P, Weiss-Laxer N, Heimer R. Police training to align law enforcement and HIV prevention: preliminary evidence from the field. Am J Public Health. 2011;101:2012–2015. doi: 10.2105/AJPH.2011.300254. [DOI] [PMC free article] [PubMed] [Google Scholar]
  4. Beletsky L, Ruthazer R, Macalino GE, Rich JD, Tan L, Burris S. Physicians’ knowledge of and willingness to prescribe naloxone to reverse accidental opiate overdose: challenges and opportunities. J Urban Health. 2007;84:126–136. doi: 10.1007/s11524-006-9120-z. [DOI] [PMC free article] [PubMed] [Google Scholar]
  5. Bluthenthal RN, Kral AH, Erringer EA, Edlin BR. Drug paraphernalia laws and injection-related infectious disease risk among drug injectors. J Drug Issues. 1999a;29:1–16. [Google Scholar]
  6. Bluthenthal RN, Lorvick J, Kral AH, Erringer EA, Kahn JG. Collateral damage in the war on drugs: HIV risk behaviors among injection drug users. Int J Drug Policy. 1999b;10:25–38. [Google Scholar]
  7. Bradvik L, Hulenvik P, Frank A, Medvedeo A, Berglund M. Self-reported and observed heroin overdoses in Malmoe. J Subst Use. 2007;12:119–126. [Google Scholar]
  8. Brugal MT, Barrio G, De LF, Regidor E, Royuela L, Suelves JM. Factors associated with non-fatal heroin overdose: assessing the effect of frequency and route of heroin administration. Addiction. 2002;97:319–327. doi: 10.1046/j.1360-0443.2002.00058.x. [DOI] [PubMed] [Google Scholar]
  9. Burris S, Norland J, Edlin BR. Legal aspects of providing naloxone to heroin users in the United States. Int J Drug Policy. 2001;12:237–248. [Google Scholar]
  10. Centers for Disease Control and Prevention. Community-based opioid overdose prevention programs providing naloxone - United States, 2010. MMWR. 2012;61:101–105. [PMC free article] [PubMed] [Google Scholar]
  11. Centers for Disease Control and Prevention. Prescription Drug Overdose in the United States. CDC Home and Recreational Safety Fact Sheets; Atlanta: 2014. [Google Scholar]
  12. Chen LH, Hedegaard H, Warner M. Drug-poisoning deaths involving opioid analgesics: United States, 1999–2011. NCHS Data Brief 1–8. 2014 [PubMed] [Google Scholar]
  13. Clark AK, Wilder CM, Winstanley EL. A systematic review of community opioid overdose prevention and naloxone distribution programs. J Addict Med. 2014;8:153–163. doi: 10.1097/ADM.0000000000000034. [DOI] [PubMed] [Google Scholar]
  14. Coffin PO, Galea S, Ahern J, Leon AC, Vlahov D, Tardiff K. Opiates, cocaine and alcohol combinations in accidental drug overdose deaths in New York City, 1990–98. Addiction. 2003;98:739–747. doi: 10.1046/j.1360-0443.2003.00376.x. [DOI] [PubMed] [Google Scholar]
  15. Darke S, Hall W. Heroin overdose: research and evidence-based intervention. J Urban Health. 2003;80:189–200. doi: 10.1093/jurban/jtg022. [DOI] [PMC free article] [PubMed] [Google Scholar]
  16. Davidson PJ. Circumstances of Death: An Assessment of the Viability of Using Non-Toxicological Coronial Data to Investigate Opiate Overdose Risk Factors. National Center for Research into the Prevention of Drug Abuse; Perth, Western Australia: 1999. [Google Scholar]
  17. Davidson PJ, Ochoa KC, Hahn JA, Evans JL, Moss AR. Witnessing heroin-related overdoses: the experiences of young injectors in San Francisco. Addiction. 2002;97:1511–1516. doi: 10.1046/j.1360-0443.2002.00210.x. [DOI] [PubMed] [Google Scholar]
  18. Davis CS, Ruiz S, Glynn P, Picariello G, Walley AY. Expanded access to naloxone among firefighters, police officers, and emergency medical technicians in Massachusetts. Am J Public Health. 2014;104:e7. doi: 10.2105/AJPH.2014.302062. [DOI] [PMC free article] [PubMed] [Google Scholar]
  19. Doe-Simkins M, Walley AY, Epstein A, Moyer P. Saved by the nose: bystander-administered intranasal naloxone hydrochloride for opioid overdose. Am J Public Health. 2009;99:788–791. doi: 10.2105/AJPH.2008.146647. [DOI] [PMC free article] [PubMed] [Google Scholar]
  20. Enteen L, Bauer J, McLean R, Wheeler E, Huriaux E, Kral A, Bamberger J. Overdose prevention and naloxone prescription for opioid users in San Francisco. J Urban Health. 2010;87:931–941. doi: 10.1007/s11524-010-9495-8. [DOI] [PMC free article] [PubMed] [Google Scholar]
  21. Green TC, Bowman SE, Zaller ND, Ray M, Case P, Heimer R. Barriers to medical provider support for prescription naloxone as overdose antidote for lay responders. Subst/Use Misuse. 2013a;48:558–567. doi: 10.3109/10826084.2013.787099. [DOI] [PubMed] [Google Scholar]
  22. Green TC, Zaller N, Palacios WR, Bowman SE, Ray M, Heimer R, Case P. Law enforcement attitudes toward overdose prevention and response. Drug Alcohol Depend. 2013b;133:677–684. doi: 10.1016/j.drugalcdep.2013.08.018. [DOI] [PMC free article] [PubMed] [Google Scholar]
  23. Julien RM. A Primer of Drug Action. Worth Publishers; New York: 2005. [Google Scholar]
  24. Lankenau SE, Teti M, Silva K, Bloom JJ, Harocopos A, Treese M. Initiation into prescription opioid misuse amongst young injection drug users. Int J Drug Policy. 2012;23:37–44. doi: 10.1016/j.drugpo.2011.05.014. [DOI] [PMC free article] [PubMed] [Google Scholar]
  25. Latkin CA, Hua W, Tobin KE. Social network correlates of self-reported non-fatal overdose. Drug Alcohol Depend. 2004;73:61–67. doi: 10.1016/j.drugalcdep.2003.09.005. [DOI] [PubMed] [Google Scholar]
  26. Martinez AN, Bluthenthal RN, Lorvick J, Anderson R, Flynn N, Kral AH. The impact of legalizing syringe exchange programs on arrests among injection drug users in California. J Urban Health. 2007;84:423–435. doi: 10.1007/s11524-006-9139-1. [DOI] [PMC free article] [PubMed] [Google Scholar]
  27. Maxwell S, Bigg D, Stanczykiewicz K, Carlberg-Racich S. Prescribing naloxone to actively injecting heroin users: a program to reduce heroin overdose deaths. J Addict Dis. 2006;25:89–96. doi: 10.1300/J069v25n03_11. [DOI] [PubMed] [Google Scholar]
  28. Mayet S, Manning V, Williams A, Loaring J, Strang J. Impact of training for healthcare professionals on how to manage an opioid overdose with naloxone: effective, but dissemination is challenging. Int J Drug Policy. 2011;22:9–15. doi: 10.1016/j.drugpo.2010.09.008. [DOI] [PubMed] [Google Scholar]
  29. Nielsen S, Lintzeris N. The use of sublingual buprenorphine–naloxone for reversing heroin overdose: a high-risk strategy that should not be recommended. Addiction. 2008;103:2065–2066. doi: 10.1111/j.1360-0443.2008.02385.x. [DOI] [PubMed] [Google Scholar]
  30. Office of the Attorney General. Attorney General Holder Announces Plans for Federal Law Enforcement Personnel to Begin Carrying Naloxone. Department of Justice, Office of Public Affairs; Washington, DC: 2014. [Google Scholar]
  31. Philbin MM, Pollini RA, Ramos R, Lozada MR, Brouwer KC, Ramos ME, Firestone Cruz M, Case P, Strathdee SA. Shooting gallery attendance among IDUs in Tijuana and Ciudad Juarez, Mexico: correlates, prevention opportunities, and the role of the environment. AIDS Behav. 2008;12:552–560. doi: 10.1007/s10461-008-9372-6. [DOI] [PMC free article] [PubMed] [Google Scholar]
  32. Pollini RA, Banta-Green CJ, Cuevas-Mota J, Metzner M, Teshale E, Garfein RS. Problematic use of prescription-type opioids prior to heroin use among young heroin injectors. Subst Abuse Rehabil. 2011;2:173–180. doi: 10.2147/SAR.S24800. [DOI] [PMC free article] [PubMed] [Google Scholar]
  33. Pollini RA, McCall L, Mehta SH, Vlahov D, Strathdee SA. Non-fatal overdose and subsequent drug treatment among injection drug users. Drug Alcohol Depend. 2006;83:104–110. doi: 10.1016/j.drugalcdep.2005.10.015. [DOI] [PMC free article] [PubMed] [Google Scholar]
  34. Ray B, O’Donnell D, Kahre K. Police officer attitudes towards intranasal naloxone training. Drug Alcohol Depend. 2015;146:107–110. doi: 10.1016/j.drugalcdep.2014.10.026. [DOI] [PubMed] [Google Scholar]
  35. Robertson AM, Garfein RS, Wagner KD, Mehta SR, Magis-Rodriguez C, Cuevas-Mota J, Moreno-Zuniga PG, Strathdee SA. Evaluating the impact of Mexico’s drug policy reforms on people who inject drugs in Tijuana, B.C., Mexico, and San Diego, CA, United States: a binational mixed methods research agenda. Harm Reduct J. 2014;11:4. doi: 10.1186/1477-7517-11-4. [DOI] [PMC free article] [PubMed] [Google Scholar]
  36. Rudd RA, Paulozzi LJ, Bauer MJ, Burleson RW, Carlson RE, Dao D, Davis JW, Dudek J, Eichler BA, Fernandes JC, Fondario A, Gabella B, Hume B, Huntamer T, Kariisa M, Largo TW, Miles J, Newmyer A, Nitcheva D, Perez BE, Proescholdbell SK, Sabel JC, Skiba J, Slavova S, Stone K, Tharp JM, Wendling T, Wright D, Zehner AM. Increases in heroin overdose deaths - 28 States, 2010 to 2012. MMWR. 2014;63:849–854. [PMC free article] [PubMed] [Google Scholar]
  37. Seal KH, Kral AH, Gee L, Moore LD, Bluthenthal RN, Lorvick J, Edlin BR. Predictors and prevention of nonfatal overdose among street-recruited injection heroin users in the San Francisco Bay Area, 1998–1999. Am J Public Health. 2001;91:1842–1846. doi: 10.2105/ajph.91.11.1842. [DOI] [PMC free article] [PubMed] [Google Scholar]
  38. Sergeev B, Karpets A, Sarang A, Tikhonov M. Prevalence and circumstances of opiate overdose among injection drug users in the Russian Federation. J Urban Health. 2003;80:212–219. doi: 10.1093/jurban/jtg024. [DOI] [PMC free article] [PubMed] [Google Scholar]
  39. Sherman SG, Cheng Y, Kral AH. Prevalence and correlates of opiate overdose among young injection drug users in a large U.S. city. Drug Alcohol Depend. 2007;88:182–187. doi: 10.1016/j.drugalcdep.2006.10.006. [DOI] [PMC free article] [PubMed] [Google Scholar]
  40. Silverman B, Davis CS, Graff J, Bhatti U, Santos M, Beletsky L. Harmonizing disease prevention and police practice in the implementation of HIV prevention programs: up-stream strategies from Wilmington, Delaware. Harm Reduct J. 2012;9:1–9. doi: 10.1186/1477-7517-9-17. [DOI] [PMC free article] [PubMed] [Google Scholar]
  41. Stoove MA, Dietze PM, Jolley D. Overdose deaths following previous non-fatal heroin overdose: record linkage of ambulance attendance and death registry data. Drug Alcohol Rev. 2009;28:347–352. doi: 10.1111/j.1465-3362.2009.00057.x. [DOI] [PubMed] [Google Scholar]
  42. Tobin KE, Davey MA, Latkin CA. Calling emergency medical services during drug overdose: an examination of individual, social and setting correlates. Addiction. 2005;100:397–404. doi: 10.1111/j.1360-0443.2005.00975.x. [DOI] [PubMed] [Google Scholar]
  43. Tyndall MJ, Craib KJ, Currie S, Li K, O’Shaughnessy MV, Schechter MT. Impact of HIV infection on mortality in a cohort of injection drug users. J Acquir Immune Defic Syndr. 2001;28:351–357. doi: 10.1097/00126334-200112010-00008. [DOI] [PubMed] [Google Scholar]
  44. Wagner KD, Iverson E, Wong CF, Bloom JJ, McNeeley M, Davidson PJ, McCarty C, Kral AH, Lankenau SE. Personal social network factors associated with overdose prevention training participation. Subst Use Misuse. 2013a;48:21–30. doi: 10.3109/10826084.2012.720335. [DOI] [PMC free article] [PubMed] [Google Scholar]
  45. Wagner KD, Simon-Freeman R, Bluthenthal RN. The association between law enforcement encounters and syringe sharing among IDUs on skid row: a mixed methods analysis. AIDS Behav. 2013b;17:2637–2643. doi: 10.1007/s10461-013-0488-y. [DOI] [PMC free article] [PubMed] [Google Scholar]
  46. Wagner KD, Valente TW, Casanova M, Partovi SM, Mendenhall BM, Hundley JH, Gonzalez M, Unger JB. Evaluation of a comprehensive overdose prevention and response training programme for injection drug users in the skid row area of Los Angeles, CA. Int J Drug Policy. 2010;21:186–193. doi: 10.1016/j.drugpo.2009.01.003. [DOI] [PMC free article] [PubMed] [Google Scholar]
  47. Warner-Smith M, Darke S, Lynskey M, Hall W. Heroin overdose: causes and consequences. Addiction. 2001;96:1113–1125. doi: 10.1046/j.1360-0443.2001.96811135.x. [DOI] [PubMed] [Google Scholar]
  48. Welsh C, Sherman SG, Tobin KE. A case of heroin overdose reversed by sublingually administered buprenorphine/naloxone (Suboxone®) Addiction. 2008;103:1226–1228. doi: 10.1111/j.1360-0443.2008.02244.x. [DOI] [PubMed] [Google Scholar]
  49. Yokell MA, Zaller ND, Green TC, McKenzie M, Rich JD. Intravenous use of illicit buprenorphine/naloxone to reverse an acute heroin overdose. J Opioid Manage. 2012;8:63–66. doi: 10.5055/jom.2012.0098. [DOI] [PMC free article] [PubMed] [Google Scholar]
  50. Young AM, Havens JR. Transition from first illicit drug use to first injection drug use among rural Appalachian drug users: a cross-sectional comparison and retrospective survival analysis. Addiction. 2012;107:587–596. doi: 10.1111/j.1360-0443.2011.03635.x. [DOI] [PMC free article] [PubMed] [Google Scholar]

RESOURCES