The present study examined characteristics of urban drug users in a community sample who have witnessed many overdoses throughout their drug use career and how the actions taken at the last witnessed overdose relate to the number of overdoses ever witnessed. We found a number of factors to be significantly associated with the count of overdoses ever witnessed. Persons who are male, who have experienced homelessness, who have used heroin, and who have overdosed themselves may witness more overdoses over their drug use careers. Additionally, a key finding of this study was that those persons who have witnessed more overdoses were less likely to have sought medical assistance and more likely to report potentially dangerous, counter-productive or ineffective actions at the last overdose they witnessed compared to persons who had only ever witnessed one or two overdoses.
We found evidence that individuals who themselves have greater overdose risk witness more overdoses. If the majority of overdoses witnessed by drug users are those of individuals in their drug network, the apparent correlation between personal overdose risk and the count of overdoses ever witnessed suggests that overdose risk may be concentrated within particular drug networks with riskier drug use norms (e.g., preferences in drugs or drugs used in combination, route of administration) (Latkin et al., 2004
), though more research is still needed to support this conclusion. Similarly, among injectors, higher numbers of witnessed overdoses were reported by those individuals who have injected multiple drugs together, a behavior which is also associated with greater overdose risk (Ochoa et al., 2001
; Seymour et al., 2000
). These findings suggest that individuals who themselves have increased overdose risk are potentially key targets of overdose witness training intervention efforts, consistent with prior studies that have found that individuals who have overdosed are less likely to call for emergency medical services when witnessing an overdose (Tobin et al., 2005
; Tracy et al., 2005
). The present findings (including the finding that 56.3% of non-fatal overdoses experienced by those in the sample were witnessed by someone using drugs) also provide some validation of the network-based approach to interventions to date (Green et al., 2008
; Markham Piper, 2008
; Seal et al., 2005
; Strang et al., 2008
; Tobin et al., 2008
The implications of the association with Narcotics Anonymous are complicated due to the unknown temporality of the cross-sectional data. Individuals who have witnessed more overdoses may be more likely to enter treatment as a result of those experiences (Pollini et al., 2006b
). Consequently, many of the overdoses witnessed by those participants who have attended Narcotics Anonymous may have occurred before, rather than after, attendance at Narcotics Anonymous. Treatment history is likely associated with severity of substance use problems in this sample, which may explain the association between Narcotics Anonymous attendance and count of overdoses ever witnessed. However, we did not find evidence that persons who had attended methadone maintenance treatment have also witnessed more overdoses than those who do not. Nonetheless, given the particularly notable increases in methadone-related overdoses in recent years (Fingerhut, 2008
), programs which distribute methadone may still have an important role in overdose prevention efforts.
Several aspects of the present findings raise particular concern for overdose prevention efforts. We found that those individuals who witness more overdoses are more likely to report not getting medical help for the victim at the last overdose they witnessed. It is possible that past negative experiences with calling for help during previously witnessed overdoses have discouraged drug users with a history of many witnessed overdoses from calling for help at the most recent overdose. However, the likelihood of delaying or preventing calling for help because of fear of police involvement did not differ across groups. Further research is needed to examine if other aspects of getting help, such as interactions with emergency medical staff (Neale, 1999
), differs between these groups. We did find that individuals who had witnessed eleven or more overdoses were more likely than individuals who had witnessed few overdoses to report not seeking or delaying getting medical help for the victim because they believed that they could handle it on their own. Despite this belief, individuals with a high count of witnessed overdoses were no more likely to report that CPR was provided to the victim, that the victim was checked for consciousness, or that the victim lived. Additionally, individuals who had witnessed more overdoses were also more likely to report taking potentially dangerous and/or less effective actions in response to the overdose, including injecting the victim with salt, water, speed, or bleach. These associations were not accounted for by length of drug use career. Taken together, these findings suggest that those individuals who may have the most frequent opportunities to intervene and reduce the risk of death are no more likely to intervene appropriately, and are actually more likely to intervene inappropriately, than individuals who are have only had few opportunities to intervene. More research is needed to understand the specific psychoeducational needs for these individuals to combat myths about effective reversal of an overdose and overcoming resistance to seeking medical help for the victim.
This finding has important implications for witness-based overdose prevention efforts. Clearly, individuals who have witnessed many overdoses are a key target of network-based overdose witness interventions because of the association of count of overdoses witnessed with ineffective or potentially dangerous actions taken at the last witnessed overdose. Stakeholders such as law enforcement officials and emergency medical service staff may be well-positioned to provide referrals or other information to the witnesses at an overdose or to identify individuals who have been present at multiple overdoses and link those persons to witness training services.
There are several limitations to this study. The data were retrospective and cross-sectional, and subject to errors and biases in recall. Longitudinal data would aid in understanding causal relations between individuals' characteristics and behaviors with the frequency of witnessing overdoses. It is possible that individuals who witnessed more overdoses preferred revival strategies that are potentially dangerous and/or were hesitant to call for medical help prior to having witnessed any overdoses, with these beliefs remaining unchanged by experience, rather than their prior overdose witnessing experiences affecting these beliefs and behaviors. However, this distinction does not alter the inference that individuals who have witnessed many overdoses are an important target of response training. The recruitment methods do not allow for a calculation of the percentage of eligible participants who refused participation. Participants may have underreported the number of overdoses they have witnessed in an effort to expedite the interview. The study was also limited to one geographic region, and findings may be different for other geographic areas with other drug use norms. Data were collected prior to the passing of a law in New York in 2006 which legalized the use of naloxone by non-medical persons for the purpose of treating an overdose (New York State Department of Health, 2011
), and findings regarding actions taken at overdoses may have been influenced by this change. The present study is not able to address ways to reduce overdose fatality that occur when the overdose victim is alone.
Despite these limitations, this study has several important implications for overdose fatality prevention. Individuals who themselves are at high risk for an overdose, such as those individuals who have had a prior non-fatal overdose (Coffin et al., 2007
) and who inject multiple drugs together (Ochoa et al., 2001
; Seymour et al., 2000
), are likely to witness more overdoses and consequently are important targets of overdose prevention interventions. Males, heroin users, and individuals who have experienced homelessness also are also likely to witness more overdoses than individuals without these characteristics. Community-based programs for homelessness may be one appropriate setting for overdose fatality prevention training. Unfortunately, individuals who have witnessed more overdoses also are more likely to report that potentially dangerous and/or less effective actions were taken and less likely to report that medical help was sought for the victim at the last overdose witnessed. This finding suggests that targeting overdose fatality prevention interventions for individuals likely to witness many overdoses is sorely needed in order to have an impact on witness behavior.