Reducing the Iatrogenesis of Police Overdose Response: Time Is of the Essence

In their article in this issue, White et al. (p. 1326) use a novel data source to provide insight into the police response to 911 calls for opioid overdose. They analyzed the body-worn camera footage of 168 police overdose responses over a 15-month period in Tempe, Arizona, with notable results: after a mean response time of 5:01 minutes, police arrived in advance of medical personnel 73.7% of the time, administered naloxone in 74.1% of the cases, and performed cardiopulmonary resuscitation on 33.5% of the victims. None expressed false beliefs about accidental fatal fentanyl exposure. ¹ Officers arrested six overdose survivors and two bystanders for felony warrants (3.6% and 1.2% of cases, respectively), but declined to arrest eight victims who had warrants for less-serious charges. There was a 94.6% survival rate associated with these incidents, although it is impossible to tell how many people would have died were it not for a police response.

THE PROMISE AND PERILS OF POLICE OVERDOSE RESPONSE

In a nation with fatal opioid overdose rates that have shattered all historical records, these data suggest a distinct role for police in opioid overdose reversal. Seconds count, not only to reduce mortality but also to minimize the sequalae of overdose, which can include hypoxic or anoxic brain injuries. While police often respond faster than medical personnel in rural settings with few resources spread over a large area, ² the study by White et al. shows they also often respond faster in a well-funded urban environment with a population of more than 191 000 residents. Officers responded quickly, acted decisively, and properly administered naloxone (although they frequently administered a second dose too soon, which can unnecessarily intensify withdrawal). The results suggest that in Tempe police have saved people from overdose death and that police departments are positioned to do so elsewhere.

The study is not an unqualified endorsement, however. We do not know from the data how many people never called 911 for fear of arrest on a warrant or for new charges, or because they distrust police, all of which people who use drugs report to be considerable barriers. ³ Arizona’s Good Samaritan Law protects callers and victims from arrest for a range of offenses, but not for warrants, or for probation or parole violations. Among the other disruptions caused by arrest and incarceration (such as delays in accessing care and treatment), they can send people with opioid use disorder into a painful state of withdrawal, unpredictably alter their tolerance for opioids, and significantly increase their risk of fatal overdose upon release, ⁴ an ironic consequence of calling 911 to save a person’s life.

As with other outcomes in policing and health, the iatrogenic effects of a police overdose reversal stand to be much more acute for minorities and the economically disadvantaged, as both demographics are more likely to have the warrants and violations that yield arrest because of the systemic disparities in our criminal justice system. ⁵ A police overdose response coupled with opportunistic enforcement will further exacerbate these problems, and 37% of the overdose victims in the Tempe study were Black or Latinx.

This suggests that we should use caution in prioritizing the police for increased naloxone distribution if there are more effective alternatives. In that vein, evidence calls for an expansion of community naloxone programs for laypeople, especially ones that serve those most likely to be present at an overdose. They are positioned to provide the fastest possible administration of naloxone, further increasing the odds of a successful overdose reversal without lasting effects. Models show that community distribution of naloxone is most effective at saving both lives and money, followed by distribution to first responders, ⁶ while lessening disparate collateral consequences. If the goal is to have naloxone present at 80% of witnessed overdoses, another recent model found Arizona to be the only state among the 12 studied with adequate supplies of the medication on hand. ⁷ A firm focus on mortality reduction therefore suggests community naloxone distribution at the right focal points should be a top priority, with police programs as a secondary complement. In the meantime, one of the critical things that states can do is promptly enact strong Good Samaritan Laws for overdose victims and 911 callers. Doing so would unambiguously instruct police to emphasize saving lives over arrest by codifying it in statute. The law in Arizona is stronger than some, but it falls short of those in at least seven other states that prohibit arrest in the widest range of cases, including for probation and parole violations. ⁸

THE POTENTIAL OF PROACTIVE INNOVATION AND REFORM

Until such laws are enacted, nothing prevents police departments from proactively turning guidance into formal policy. A majority of officers surveyed in multiple states report substantial or near-complete discretion in making misdemeanor arrests during encounters with people who use drugs, ⁹ Tempe police leaders de-emphasize arrests during overdose response in their training, and officers in the study sample declined to arrest more than half of the overdose victims found to have active warrants. Although police should not be expected to ignore felony warrants for violent crimes, the use of discretion in warrant enforcement is not uncommon in municipal agencies. ⁵ Formal policies that prohibit arrests for misdemeanor warrants or a failure to appear in court would establish clear norms and expectations. Such de facto policies in advance of de jure changes to the law would not be entirely unheard of: as a lifesaving measure, law enforcement officials in Burlington, Vermont, and Philadelphia, Pennsylvania, adopted a categorical policy of not arresting people for the misdemeanor possession of the unprescribed addiction medication buprenorphine in 2018, ¹⁰ three years before Vermont and Rhode Island formally struck the relevant statutes from their penal law.

As police pursue naloxone programs, their leaders should carefully consider the powers and challenges of the police role. Of all the public actors who could effectively respond to an opioid overdose at present, they are among the best situated, but also the only ones with the power of arrest. In the context of an acute health emergency, it is a power that seems unnecessary and misplaced. If any other system were just as widespread and well-funded, it could replicate a police response with none of the iatrogenesis unique to policing. But data from Illinois I am preparing for publication show that 69.2% of the 224 police officers surveyed agreed that “carrying naloxone to reverse opioid overdoses is a police officer’s duty,” a sentiment echoed by previous research into officer attitudes and beliefs in Tempe. ¹¹ If it is a duty the police intend to honor, police departments need to reconcile the inherent tension between their lifesaving and law enforcement roles. To truly maximize the potential of first-responder naloxone programs, officers need to gain the trust of 911 callers and encourage bystanders to seek help without hesitation or fear.

As public servants in a society that has reflexively criminalized nearly all aspects of substance misuse and addiction, police appear to have backed into the role of overdose response by virtue of proximity rather than design. If police executives are ready to truly abandon our failed war on drugs, then they should use a public health lens to formulate a police response to opioid overdose that places harm reduction over arrest with fidelity and persistence. Given the nation’s staggering overdose death toll, it is relatively low-hanging fruit at a moment when we have no time to spare.