Life after opioid-involved overdose: Survivor narratives and their implications for ER/ED interventions

Abstract

Background & Aims

Numerous states in the U.S. are working to stem opioid-involved overdose (OD) by engaging OD survivors before discharge from emergency departments (EDs). This analysis examines interactions between survivors and medical care providers that may influence opioid risk behaviors post-OD.

Design

Qualitative stakeholder analysis involving in-depth interviews with samples from three groups.

Setting

Two Hospitals in high OD-mortality neighborhoods in New York City (NYC), USA.

Participants

Total N=35: emergency medical services personnel (EMS; n=9) and ED medical staff (EDS; n=6) both working in high OD-mortality neighborhoods in NYC; recent opioid-involved OD survivors who had been administered naloxone and transported to a hospital ED (n=20).

Measurements

EMS and EDS interviews examined content of verbal interactions with survivors and attitudes related to people who use opioids. Survivor interviews addressed healthcare experiences, OD-related behavioral impacts, and barriers to risk-reduction post-OD.

Findings

Both EMS and EDS stakeholders described frequent efforts to influence survivors’ subsequent behavior, but some acknowledged a loss of empathy, and most described burnout related to perceived ingratitude or failure to influence patients. Survivors reported being motivated to reduce opioid risk following a non-fatal OD and many described successful risk-reduction efforts post-OD. Intentions to cease opioid use or reduce risk were complicated by unmanaged, naloxone-related withdrawal, lack of social support, and perceived disrespect from EMS and/or EDS.

Conclusions

Emergency department interventions with opioid-involved overdose (OD) survivors may benefit from training emergency medical staff to assure a continuity of nonjudgmental, socially supportive remediation attempts across contacts with different caregivers. Brief interventions to educate emergency medical staff about current theories of addiction and evidence-based treatment may achieve this goal while reducing caregiver burnout and improving the uptake and efficacy of post-OD interventions delivered in emergency departments.

INTRODUCTION

Since the 1970s, emergency medical services (EMS) have had access to the opioid antagonist, naloxone, when responding to overdoses involving opioids. Current internationally-recognized best practices call for professional post-resuscitation care to assess the survivor and prevent rebound opioid toxicity related to naloxone’s short half-life relative to that of most opioids [1]. The United States, the world’s largest consumer of opioid drugs [2], is currently experiencing an epidemic of opioid-involved overdose (OD) morbidity and mortality [3, 4], and post-OD care is typically given within hospital emergency departments (EDs).

Given the large number of non-fatal ODs for every fatality—a 20:1 ratio or greater by one estimate [5]—the burden of OD response upon EMS and emergency department staff (EDS) during an epidemic is pronounced [6, 7]. News media and professional forums frame the emergence of OD response-related fatigue, or “burnout,” among professional first responders disillusioned by repeat ODs and the failure of a non-fatal OD to provoke behavioral change [8, 9]. Some health-care providers also hold negative views of people who use drugs (PWUD), in part due to their perceived overuse of resources and failure to adhere to recommended care [10, 11], and a number of interventions have been designed to reduce stigma toward PWUD among medical students [12–14] and nurses in training [15].

The process by which medical personnel transfer a patient from one form of care to another is commonly referred to as a “handoff” in healthcare delivery research [16–18]. The handoff process is particularly salient within the context of OD, as survivors are moved from ambulance-based care to ED care and then, increasingly, into a growing array of substance use treatments [19, 20] and care navigation interventions [21–23] situated within the same hospital. In the U.S., at least 10 states have received federal funding to develop handoff procedures that transfer opioid-involved OD survivors to care navigation interventions immediately after an OD event [24]. Increasingly, these interventions are delivered by trained “peers,” individuals with histories of opioid use disorder and successful treatment [22]. Despite the current enthusiasm for engaging OD survivors in EDs, little evidence supports the efficacy of these interventions. One recent study evaluated a brief educational intervention designed to reduce opioid-involved risk behaviors among high-risk persons who use opioids after opioid-related ED care [25] but found no significant impacts on subsequent OD events. More robust interventions that provide non-stigmatizing social support and incorporate harm reduction into clinical practice [26–28] may effectively reframe non-fatal OD as a positive turning point [29] within a drug use “career” [30], but this remains speculative at present.

To date, the ways in which a survivor conceives of an OD experience after the fact (and the impact of that conceptualization upon subsequent risk behavior) have yet to be systematically explored in public health research. Similarly, the extent to which those experiences are shaped by the content of survivors’ interactions with EMS and EDS remains unclear. Professional pessimism about treatment, judgments of resource misallocation, or a lack of empathy toward PWUO [11, 31–34] may create a counterproductive environment for ED based interventions. By the same token, EMS and EDS who engage OD survivors in non-judgmental, supportive ways—presenting evidence-based treatment and other forms of risk-reduction—may already represent an understudied protective factor in post-OD survivor outcomes.

To begin to address some of these questions, this article presents the results of an exploratory qualitative analysis examining the experiences of three stakeholder groups involved in non-fatal, opioid-involved overdose events—the individuals experiencing overdose, the EMS personnel responding to the overdose, and the EDS who tend to OD survivors.

METHODS

Study design

The following is a stakeholder analysis designed to assess the potential impacts of survivors’ social interactions with EMS and EDS upon subsequent behaviors and attitudes.

Stakeholder analysis has been of particular value in healthcare and hospital management [35–38] and is generally viewed as a critical tool for establishing policy that converges around the interests, resources and vulnerabilities of potentially divergent social or occupational groups [39, 40].

Recruitment

Survivors of opioid-involved overdoses were recruited using purposive sampling and through referrals from staff at New York City (NYC) syringe exchange programs. Opioid-involved OD survivors were contacted and invited to participate in a 30-60 minute, semi-structured interview. Of a total of 22 interviews with OD survivors, 2 involved reversals by peers and no contact with EMS or EDS and were removed from this analysis. Both EMS and EDS participants were recruited through two hospitals in Manhattan neighborhoods experiencing some of the highest opioid-involved overdose mortality rates in the borough [41]. A senior emergency room physician at both hospitals made introductions to the hospitals’ EMS personnel and invited study staff to introduce the project after an ED staff meeting. Interested EMS and EDS subsequently contacted our study team to arrange interviews. All participants were compensated $40 for their time (roughly 30 minutes per interview). All interviews were digitally recorded and transcribed for coding and analysis in MAXQDA [42].

Qualitative stakeholder interviews

Qualitative interviews focused social interactions between OD survivors and EMS in an ambulance and survivors and EDS in an ED.

Interviews with EMS and EDS focused on individuals’ experiences with opioid-involved OD survivors and elicited narratives about personal approaches to communicating with those survivors. Participants in these two groups were asked about the emotional impact of working with OD survivors and what strategies would better support PWUO in the aftermath of an OD event.

The qualitative interview guide for OD survivors included a small subset of a priori concepts of interest related to OD events, the forms of acute care received, psychosocial dimensions of surviving an OD and opioid-related risk behaviors subsequent to an OD. Interviewing consisted of queries about individuals’ most recent overdose experiences and involved prompts drawn from timeline follow-back interviewing methods [43, 44] to aid in participant recall and “anchor” the periods preceding and following an OD.

Coding

Coding procedures were conducted by the three study authors - each reading a sample of 3 full transcripts and independently coding with an inductive “open coding” approach [45] to establish a preliminary list of themes and code categories. Authors met to discuss and refine the codebook, comprising a list of 46 items, 24 of which related to this analysis’ focus on the impacts of OD across stakeholder groups. Authors coded all participant cases into one of three basic code categories related to post-OD risk-reduction—immediate change in OD risk behaviors or opioid use; delayed change in risk/use; and no change in risk/use. Any divergence in coding was resolved in group discussion. Interviews with EMS and EDS were similarly assigned to code categories related to histories of informal interventions with OD survivors and expressions of frustration, fatigue, or burnout. Basic coding counts related to these categories are provided with participant demographics in Table 1 below.

Table 1 –

Participant Characteristics for all Stakeholder Groups

	EMS	EDS	Survivors
Sample Size	9	6	20
Age Range	21-41	28-52	22-60
Male	8 (89%)	4 (67%)	16 (80%)
White	6	4 (67%)	8 (40%)
Black/African American	3	0	4 (20%)
Asian	0	1 (17%)	0
Latino		1 (17%)	8 (40%)
History of Verbal Intervention	6 (67%)	6 (100%)	n/a
Intent to Change Post-OD	n/a	n/a
Immediate			12 (60%)
Delayed			2 (10%)
None			8 (30%)

All procedures were approved by the host institutional review board, and all given names used below are pseudonyms selected by participants.

RESULTS

We present findings below organized by stakeholder group: EMS attitudes and experiences are followed by those of EDS (in parallel with the standard progression in post-OD care) after which survivor experiences are analyzed.

EMS Perspectives

Five participating EMS were emergency medical technicians (EMTs), the entry level care provider within EMS in the U.S., who, in 2013 in New York State, became authorized to administer naloxone [46]; the other 4 were paramedics, who receive considerably more training in medicine and pharmacology [47]. Years in EMS ranged from 3 to 21 with 11 years being the average duration of employment in the industry. All reported extensive experience with opioid-involved ODs and naloxone administration.

Elicited accounts of conversations with survivors established an important indication of both the desire to impact post-OD behaviors as well as fatigue from the belief that appropriate, well-intentioned advice is typically ignored. Steve (White Male, 28 years) explained:

You might have a day where you get 2 or 3 [ODs] from a bad batch going around. It’s just like we see the same people, the same type of person…It kind of weighs on you because you feel like they don’t want help. It’s totally different from someone who gets in a car accident on their way to school or work…really trying to live their life. It definitely crosses your mind, but feeling that affects your care of a patient in a job like this. I say we never treat anyone differently, but everyone has stereotypes.

For the most experienced paramedic in the sample, George (White Male, 40 years) with 20 years in EMS, watching the opioid epidemic escalate in the U.S. brought him to a strong judgment of PWUO who make a decision to use opioids despite, “knowing wrong [from] right. [For some] they know it’s wrong and they still do it….So who do you blame?”

Espousing the view that opioid dependence for some is a moral failing—a decision to choose the wrong, despite awareness of what is right—George explained how learning to cope when responding to OD emergencies involved gradually learning to use smaller doses of naloxone (while performing ventilation) to avoid difficult interactions with survivors experiencing severe withdrawal symptoms.

One third of EMS participants stated current preferences for avoiding unnecessary conversation with survivors, but all spoke of having done so at various points in their careers. John (White Male, 27 years) commented: “I don’t have a standard line but you do want to try to talk to them about [their OD] really,” In some accounts, EMS assumed the role of educators, explaining how drug misuse would eventually destroy vital organs and lead to death; in others, they described attempts to shock or scare survivors into changing their behaviors. Jane (East Indian Female, 30 years) related a story of a relatively “good” OD reversal involving a young male unconscious on the street:

He thanked me! He goes, “Thank you because I don’t know what happened. I can’t recall anything.” I was like, “dude, you were in the rain…dead. I mean, I understand if you drink, you passed out, whatever, but, you did a little extra [i.e., opioids]. And, now, look where you are.” It’s like a reality check. Sometimes it’s just your time to hopefully educate someone and you don’t want them to be repeat patient.

Jane’s story here stands in contrast to the bulk of those collected. When asked about EMS success in discussing positive health change with OD survivors, more than half of the sample expressed feelings of frustration, fatigue and/or burnout. Martin (White Male, 36 years) explained:

[Responding to OD calls] is taxing. It takes away from what I would call real patients…When I hear you took this drug by yourself and I have to go save your ass, how is that fair?

Drew (White Male, 25 years) explained how resentment over wasted time and resources had gradually come to characterize his relationship to OD survivors:

You know at the beginning it was exciting: I saved their lives. Now…there are frequent flyers and we see them over and over again and it comes to a realization. We’re like, “Okay we saved you this time. For what? For you to do it again?

These brief interview segments suggest that informal conversational interventions by EMS may be commonplace and that some are rooted in outdated stereotypes that perceive substance misuse as a moral failure and selfish behavior.

EDS Perspectives

The EDS participants included 5 medical doctors and 1 physician’s assistant. Interviewers asked them to describe their interactions with OD survivors prior to being asked about opportunities for staging more formal interventions in ED settings.

For all EDS interviewees, communication with OD survivors was presented as a necessary component of ED care, a theme captured in the following brief statements:

Marie (Latina, 36 years): I discuss with all my patients what happened. And I tell them, you know, like, “You need to stop using drugs.”

Dr. Fred: (White Male, 53 years): I really have to [try to talk to survivors], you know, because even when we see them here and we reverse them, how do you motivate somebody to then get to care?

A number of EDS described verbal interaction as common but something to be minimized, due to perceptions that patients who use opioids are apathetic, unreceptive, and, in some cases, overmedicated. Dr. G (South Asian Female, 55 years) described her pessimism and its tolls:

I don’t know if [the ED] is the right environment to tell them, “Hey, listen, you would have been dead if you didn’t get this medication!” Most of them don’t want to hear it. I have not met one person who would say thank you… If I’m going to see the same person over and over again, at some point, I’m not going to have any compassion.

To an even greater extent than the EMS group, ED staff expressed their fatigue and their frustration related to a perceived lack of gratitude in survivors. Echoing Dr. G’s statement above, Joe (White Male, 30 years) recounted a stereotypical interaction with survivors:

“I just watched you all night and made sure you’re okay and you’re not even thanking me: you’re going to sit here and yell at me!”

For Peter (White Male, 29 years), the perception that people with opioid dependencies are unreasonable was extended to those undergoing medication assisted treatment as well:

I can reason with a heroin addict. I can reason with a pill popper. I cannot reason with a methadone addict. I’ve had patients storm out of the ED because I dare to say that their 120 milligrams of methadone might be the cause of their constipation!

I see so many who are telling me that they recently got raised from 80 to 100 [mgs per daily dose], which is just absurd. These patients shuffle around and sleep, and that’s all they do with their life.

While Peter’s commentary was more vitriolic than those of his colleagues, his lack of clinical understanding of methadone’s standard dosing range [48] and prejudice toward evidence based pharmacological treatment represents another potential disconnect between EDS attitudes and the explicit aims of post-OD care navigation interventions.

In summary, EDS participants presented a relatively unified view of their perceived responsibility to engage OD survivors and educate them about less risk-oriented behavior. In interviews, however, EDS efforts to promote meaningful change appeared compromised by a loss of empathy, frustration with ingratitude, and even skepticism about the efficacy of treatment.

Overdose Survivor Perspectives

Interviews with survivors provided an opportunity to juxtapose personal OD experiences with the perceptions of professional caregivers and to conceptualize some of the ways in which the experiential dimensions of an OD may impact subsequent opioid risk behaviors.

Post-OD Behavioral Change.

Participants who changed their substance use patterns immediately after surviving an OD described a range of behavioral changes. For two, OD led to immediate and successful efforts to cease all illicit opioid use. Two other participants described attempts to cease heroin use immediately following their OD; both did so without social or medical support and reported returning to their pre-OD use while in withdrawal, suggesting the severity of opioid dependence may moderate the impact of post-OD interventions.

Others described surviving an OD as an opportunity to reduce the risk of OD. Three participants explained that the primary outcome of their OD was a subsequent resolution not to inject. For 3 other participants, harm minimization took the form of a new practice of doing “test shots” to determine the potency of a new purchase of heroin before injecting their full, desired dose, particularly given the current prevalence of fentanyl analogues in illicit opioids. Nena (Latina, 43) reported using with others in possession of naloxone after she overdosed alone in a park, received naloxone from EMS, spent 5 hours in an ED, and was then threatened with arrest. Two other participants explained that their ODs had taught them valuable lessons about mixing benzodiazepines with opioids, a practice they both curtailed post-OD.

Although most of the accounts of behavioral change post-OD suggested an immediate response to the experience, two participants explained how surviving an overdose became a reminder of their own mortality that, over the subsequent year, led to harm-reducing change. For Joker (Latino, 48 years), using heroin post-OD always involved being “really nervous” until he learned to practice safer injection by taking a test shot. For Dee, who suspected having been raped during her OD, change came slowly as she initiated methadone-based treatment, stopped mixing pills with heroin, and began to address her sexual abuse history in therapy.

Despite the evident impact of surviving an OD on many participants, a number also offered clear reports of unaltered use patterns following their experiences. Sunshine (African-American Female, 37 years), for example, continued to use two bags of heroin a day, the same amount of which led to her overdose. John (White Male, 58 years) informed his interviewer that he is a “pure junkie” and unlikely to ever stop injecting heroin, especially after the loss of his wife to a fatal OD, an event that led to an escalation in his heroin use. Lou (Latino, 39 years) described a decision-making process whereby he ultimately elected to continue enjoying potentially dangerous doses of heroin after his first of several ODs, ultimately leading to what he believed were upward of 12 lifetime OD events. When “issues” are left on the “backburner,” he explained, being revived by naloxone and left in a state of withdrawal can present a scenario in which a return to self-medicating behaviors are the only apparent way of coping with the struggles of a “cheap life” lacking in friends and other meaningful supports.

Barriers to change.

Beyond inquiring whether and how OD experiences had impacted risk behavior, we asked all participants about factors that either aided or complicated risk-reducing change in the immediate aftermath of their ODs. The majority (9 of 14) of the participants who did describe risk-reducing behavioral change cited fear as the principal motivator. For several, however, it was not so much fear of death—which for a number of participants, like Lou above, seemed to lack—as the imagined impact on loved ones that was presented as the main reason for reducing risks after their ODs. As John candidly suggested in his narrative about failing to reverse his own wife’s OD, having no social supports or loved ones can make the prospect of changing a longstanding relationship to heroin undesirable and untenable, where for those with spouses, children, or family responsibilities of any nature, contemplation of the social repercussions of a fatal OD appeared a potent precipitant of behavioral change. Clark (White Male, 38 years) offered an account of the imagined impact of his passing on his family, making clear the important role played by social supports during the period following an OD:

I felt horrible: like, my mom has cancer, she is on hospice and just the fact of me being so close to dying like it…devastated like my whole family that I [might have] died and now like within days, weeks like my mom is going to die, like I felt so bad for that.

If fear and social relationships were the two primary facilitators of meaningful change noted by participants, barriers to change centered on shame, despair, and the challenge of managing withdrawal symptoms without assistance. A number of participants recounted negative experiences with EMS, several going into detail. Two participants offered the belief that the dosage of naloxone they had received was excessive, hastening their departures from ED care. Nickels (White Male, 30 years), for example, recounted:

I got hit with four vials of naloxone. I could barely keep water down, couldn’t keep food down. It was horrible. That was my worst experience.

Mike (White Male, 40 years) had experienced two ODs involving EMS response. His first OD event involved EMS who were “cool” and “pretty nice.” Asked to elaborate, he replied, “They just said, ‘Dude, stick to your methadone and stop fucking around with the dope. You’re going to die.’” After a recent OD, however, interactions with EMS were decidedly less positive:

They stereotyped me from the get go…kind of like, “Oh, another junkie that we have to deal with.” [One] was very rude: She was like, Oh, you’re into witchcraft and all that?” She kept saying I was a Satanist and that I’m going to hell.

Several participants cast interactions with EDS as similarly degrading. Nickels, for example, explained how his most recent OD experience was characterized less by the naloxone-related withdrawal he describes above than by his poor treatment by EDS:

The hospital staff were assholes. They left me in the hallway. I kept asking for water and they’re like, “We have none.” They pretty much was like, “Hey, fuck you junkie,” you know, because I was just living on the street. I guess my parents are the same. They would just look at me and they’re like, “Fucking drug addict.”

DISCUSSION

The growing focus on coordinated handoffs in emergency medicine [16–18] highlights the need for some degree of practical and clinical alignment between different types of care providers. While exploratory, this analysis is one of the first to investigate how transitions in care post-OD might impact outcomes for three distinct stakeholder groups. We found that both EMS and EDS participants were quick to describe the emotional burden of working with OD survivors. While upset by the ingratitude of survivors and their perceived inability to meaningfully influence subsequent risk behavior, both caregiver groups remained engaged with attempts to provoke behavioral change. That many EMS and EDS participants clearly did not espouse the non-judgmental, stigma-free attitudes toward opioid use disorder and OD that are hallmarks of peer-based interventions in harm reduction-oriented practice [26–28] is additional support for the position that healthcare workers in the U.S. need basic education in addiction theory and evidence-based treatment [49]. Stigmatizing attitudes may also be productively addressed through workplace interventions offering EMS and EDS practical tools for remediating burnout and professional fatigue resulting from work with PWUO [50].

Our findings related to OD survivors further reinforce the value of current efforts to engage survivors within the ED in the immediate aftermath of an OD. More than half of our sample (n=14/20) described harm minimizing changes subsequent to an OD reversal and presentation at an ED, demonstrating the importance of viewing an OD event as a critical turning point in the lives of PWUO. Barriers to effective risk-reduction (or opioid use cessation) were considerable. In addition to negative experiences involving EMS and EDS, survivors described the challenges of severe withdrawal, likely precipitated in some instances, at least, by large doses of naloxone. Currently, numerous formulations and concentrations of naloxone are in production, and international standards for post-OD care [1] have yet to incorporate dosing guidelines, leaving EMS to learn through experiences about how to assure rapid revival without excessive withdrawal. Given the high potential for some short-term opioid withdrawal, novel clinical approaches in some U.S. states [20, 21] are providing immediate access to methadone and buprenorphine, a measure which may improve uptake for post-OD peer-navigation interventions [22, 23] by mitigating against rapid ED departures to combat withdrawal with higher-risk opioids.

While immediate contextual factors may play extremely important roles in opioid-involved outcomes for survivors, participants’ accounts also point to the centrality of social supports post-OD. For participants without strong social ties, the senses of social obligation or shame that drove some accounts of post-OD risk reduction were absent, highlighting the enormous potential of peer-navigation interventions that engage survivors supportively and model the value of OD experience for outreach and prevention [22, 23].

STRENGTHS & LIMITATIONS

This analysis’ breadth is both a strength and a limitation. In engaging three stakeholder, we have produced timely findings about the informal methodologies of EMS and EDS, and the experiences of survivors, post-OD. In so doing, we make no claims to the representativeness of the sample or having attained qualitative saturation—an exhaustive exploration of all thematic and theoretical insights to be drawn from participants [51]. That said, the protocols for responding to opioid-involved OD are internationally mandated, and locating this research in NYC—one of several U.S. cities with the most harm reduction resources and public funding directed toward progressive substance misuse interventions—suggests strongly that the stigmatizing attitudes toward PWUO and medication-assisted treatment are likely to be common across the nation. As in all qualitative research, compensation and social desirability can act to constrain participant responses, although its impact did not appear to limit EMS or EDS stakeholders’ willingness to share pathologizing or stigmatizing attitudes with study authors. Due to this form of stigma in popular news media and among even professionally trained health care and emergency service providers, survivor participants may have been more inclined to indicate a strong motivation to reduce risk after an OD while nonetheless providing frank accounts of barriers to risk-reduction.

CONCLUSIONS

Findings from this stakeholder analysis highlight the critical importance of ED interventions, given the potentially life-changing impacts of an OD described by the majority of OD survivors. This study strongly suggests the need for considering the impact of EMS/EDS on the uptake and efficacy of interventions designed to engage survivors in the immediate aftermath of an OD. The potential benefits of engaging EMS and EDS also appear significant. Burnout, and informal reliance on stigmatizing approaches (appealing to shame or guilt, for example) are important intervention targets. Aligning the approaches taken by EMS and EDS stakeholders with those employed by peer-navigators post-OD may ultimately improve uptake and retention for new ED interventions while minimizing burnout and resentment among first-responders and medical staff.