- Emergency responders are not always equipped to provide care after a non-fatal overdose
- Researchers asked survivors and service providers how to improve post-overdose care
- Recommendations included trauma-informed training and partnerships with care providers
Experiencing a non-fatal overdose is a risk factor for future overdoses, which may be fatal. However, most overdose survivors are not connected to care following their non-fatal overdose.
A number of interventions have been developed to try to improve access to care following a non-fatal overdose. These include on-site interventions, linkage to care from emergency departments, and outreach efforts in the days following overdose.
However, gaps and barriers to engaging in care after an overdose persist. Researchers investigated the perspectives of overdose survivors and service provider responders on how to improve post-overdose care.
Study details
The study analyzed interviews with two groups of people: overdose survivors and service providers. Overdose survivors were eligible to participate if they were over 18 years old, lived in Boston, had experienced an opioid overdose in the past three months, spoke English or Spanish, and identified as Hispanic or Latino/a/x, Black, and/or White. Service providers were eligible to participate if they were over 18 years old and could speak about barriers and facilitators to accessing substance use treatment, equity, and engagement with overdose survivors from their professional or community leadership experience (e.g., experience responding to overdoses, working in policy and advocacy roles and/or providing health and social services to overdose survivors).
Participants were interviewed in person or through video conferencing. Overdose survivors also completed a demographic survey. Interviews focused on open-ended questions related to experiences and perspectives on overdose, treatment and harm reduction services.
Results
Among overdose survivors (n = 59), most identified as cisgender male (70%), had been incarcerated (85%), were experiencing homelessness (75%) and had experienced three or more overdoses in the past year (69%). A roughly equal number of people from each of the study’s eligible racial/ethnic categories were included: 39% identified as Hispanic or Latino/a/x, 31% identified as Black and 31% identified as White.
The service providers interviewed (n = 28) most commonly represented the following types of organizations: substance use disorder treatment (25%), public health (21%), detoxification or residential substance use treatment (18%), harm reduction programs (14%), community health centres (14%) and emergency medical services (EMS) or fire departments (11%). Common roles held by participants included the following: managers (36%), frontline positions (21%), physicians (14%), first responders (11%) and advocates or activists (11%).
Overdose survivors’ reactions immediately after overdose
People described experiencing intense physical and emotional reactions after their most recent overdose. Physical reactions included pain, agitation and opioid withdrawal symptoms caused by receiving naloxone. One participant described how “you always feel like shit after you get [given naloxone]; you feel sick … agitated, sweating.” Emotional reactions following overdose included feelings of sadness, anger, worthlessness, shame and guilt. Participants described feelings of self-blame and of “letting down” their friends and family.
As a result of these reactions, some participants noted that they were not in the right frame of mind to discuss service options or engage in services immediately after their overdose. Some highlighted that feeling sick and upset made them want to leave the scene quickly, rather than stay and talk with first responders. For example, one participant described how he felt after an overdose, including his immediate priority to relieve withdrawal symptoms:
“You wake up with your pants all broken down with scissors … then [first responders] are asking you ‘Hey, what’s your name? What happened?’ But you’re not in the mood … you woke up sick, dying … like all you want is drugs … I wake up and start arguing, like ‘I want to leave, I want to get out of here!’ It’s always like that, always, always, always.”
Overdose survivors’ perspectives on interactions with overdose responders
People described their interactions with those who had responded to their overdose, which included EMS, harm reduction service providers and hospital staff. Many people reported that these were positive interactions and felt that they were treated respectfully. Some felt they were treated disrespectfully or stigmatized, often by hospital staff or EMS.
Some participants reported that first responders did not offer them referrals or information about available services, reinforcing their feelings of neglect. These individuals considered it important to be offered help, even if they may choose not to engage with it in the moment. One man explained that:
“… I know [responders] can’t spend two or three hours with a person, but at least give them 10-15 minutes of conversation, like “Hey listen, do you need to go to detox? ... Do you want help?” Extend the branch … if [the person doesn’t] want the branch, if he swipes it away, okay, at least you tried.”
For these participants, being offered more attention and supports from responders could have helped build trust, even if they were not interested in immediately engaging in care.
Service providers’ perspectives on challenges in overdose response and recommendations for improvement
Service providers highlighted how trauma, stigma and judgment, as well as limitations in standard overdose response processes, create barriers for people to engage in care. Service providers discussed how overdose survivors are often focused on their immediate needs, rather than thinking about referrals to services or treatment. They noted that experiencing an overdose is a traumatic event, not necessarily “a teachable moment,” while also emphasizing that the way people are treated by responders can influence their likelihood of engaging with services in the future:
“if you’re treated for an overdose and you feel like you were significantly judged, that’s going to make you want to run away from the whole scene; you’re not going to want to deal with that.”
Service providers also noted that multiple aspects of standard overdose response processes (i.e., EMS arriving, reversing the overdose and offering transportation to a nearby hospital emergency department for monitoring) limited responders’ ability to connect survivors to services. They highlighted the following barriers inherent in standard overdose response processes:
- Police and uniformed first responders attend overdoses. For some people who use drugs, particularly those from marginalized and racialized communities, police and other responders in uniform are not trusted.
- EMS and emergency departments are designed to respond to medical emergencies, not foster connections, relationship building or discussions about longer term treatment plans.
Service providers suggested that integrating people trained in harm reduction, including those with lived experience, into overdose response processes could be a way of improving supports and providing referrals to services. An EMS responder suggested creating a “community engagement unit” that could remain on scene longer to talk with overdose survivors and help connect them to care after the EMS unit leaves.
Implications
This research has implications for programs and service providers seeking to improve overdose response and linkage to care. The researchers highlight the following key takeaways from their work:
When responding to an overdose, efforts should be made to create an environment where survivors feel physically and mentally safe enough to participate in conversation with responders. This means that efforts should be made to minimize opioid withdrawal (e.g., avoiding giving additional doses of naloxone when it is not necessary) and that responders should be trained in trauma-informed approaches. The researchers note that supervised consumption services (SCS) and overdose prevention sites (OPS) address many of the challenges raised by study participants. These services are supportive environments where staff are experts in reversing overdoses and providing compassionate, non-judgmental care, including referrals to other services.
Organizations involved in overdose response (e.g., EMS) should review their protocols to try to minimize stigmatizing and traumatic experiences. This could include avoiding removing clothing unless medically necessary and avoiding questioning the individual as soon as they regain consciousness.
In areas where a lot of overdoses occur, harm reduction organizations could try to partner with EMS and hospital emergency departments to improve care following an overdose. This could involve harm reduction service providers providing support to individuals after an overdose, including on-site, in emergency departments, and/or providing outreach in the days following overdose.
The researchers highlight that responders should offer support and referrals following an overdose, even though these offers might not be taken up. These offers can represent care for some individuals, and not receiving an offer of support may be perceived as neglect, reducing trust in service providers and their organizations. However, lack of uptake of these offers of support may be experienced as “failure” among service providers. To better support both overdose survivors and responders, overdose response processes could prioritize providing person-centred care and building trust, as opposed to service uptake, as key outcomes.
Limitations
There are several limitations of this study that are important to keep in mind. First, the study recruited participants from a neighbourhood in Boston where drug use and overdose were common. This neighbourhood also contained multiple services for people who use drugs. Recruitment occurred during the COVID-19 pandemic, which influenced the availability of services. Second, the service providers included in the study did not represent all organizations or roles involved in overdose response, and bystanders and other non-professional responders were not included. Finally, the research focused on experiences with formal systems of care and did not include experiences of having an overdose reversed by community members or peers, and the findings may not be generalizable to different places.
REFERENCE:
Paradise RK, Kimmel SD, Nurani A, et al. Building connection: overdose survivors’ and professional service providers’ perspectives on immediate post-overdose care. International Journal of Drug Policy. 2025;145: 104948.