The risk is real: Are people who witness an overdose more likely to use services to check the content and potency of their drug supply?

As deaths from drug overdoses have spiked in the U.S. and Canada, public health and medical experts have developed strategies to prevent overdose and death among people who use drugs. Drug checking services help inform people who use drugs about the content and potency of their supply, but many who could benefit do not use these services. This study found that people who witness an overdose are more likely to report using drug checking services.

WHAT PROBLEM DOES THIS STUDY ADDRESS?

The number of opioid-related overdoses has climbed rapidly in the U.S. and Canada since 2013, with deaths attributable to opioid overdose increasing by 90% in the U.S. between 2013-2017. The increasing prevalence of the highly potent synthetic opioid fentanyl being mixed with or sold as heroin and other opioids has been a main contributor to these rising overdose and death rates.

In response to this crisis, public health and medical experts have developed a number of strategies to reduce overdose risk and other harms (known as “harm reduction”) among people who use drugs. 

Services offering to identify the presence and potency of different substances in someone’s supply, known as drug checking, are one such strategy for reducing risk. Drug checking was first offered in the context of festivals where drug use and consequently drug overdose were common. These services are now being offered in communities to help drug users identify the presence and quantity of substances that substantially increase risk for overdose like fentanyl prior to using. While many users express interest in such services in hypothetical surveys, actual rates of use are low, and it can be difficult to get buy-in for these services from drug users due to concerns such as fear of being arrested for possessing the substance they are having checked. It is possible that certain events, such as witnessing an overdose, increase motivation for these services by making the risk of harm from fentanyl feel more real to drug users. In this study, the authors looked at whether witnessing an overdose was associated with higher likelihood of using drug checking services in Vancouver, British Columbia, Canada where these services were readily available.

HOW WAS THIS STUDY CONDUCTED?

This was a cross sectional study with 1,426 participants who answered questions about whether they had witnessed an overdose (either fatal or nonfatal) and whether they had used drug checking services, to see whether witnessing an overdose was associated with greater likelihood that someone had also used drug checking services. All participants had enrolled in one of three long-term research studies in Vancouver all of which recruit and follow people who report past month illicit substance use (the Vancouver Injection Drug Users Study, AIDS Care Cohort to evaluate Exposure to Survival Services, and the At-Risk Youth Study). For the current study, participants also answered demographic questions and provided information about their substance use history and related information including recent history of injection drug use in public areas, experience of overdose, and engaging in sex work or selling drugs during the past six months.

The main goal of this study was to see whether witnessing an overdose was associated with the use of drug checking services. The authors accounted for other factors that also may have influenced use of drug checking services by adjusting statistically for drug use and related behaviors in their analyses in order to better isolate witnessing the overdose as the cause of increased likelihood in drug checking service use. The authors also reported the frequency of witnessing an overdose and use of drug checking services for the overall sample.

Participants were approximately 45 years old, on average. Slightly more than a third (37%) were female, and almost half (46%) were white. A sizeable minority (20%) reported current homelessness and just over half (52%) reported suspected exposure to fentanyl over the past six months. About a third (31%) reported daily injection drug use during that period.

WHAT DID THIS STUDY FIND?

Figure 1.

More than half of the sample had witnessed an overdose in the past 6 months, while very few (14%) reported using drug checking services during the same time period.

Most (60%) who had witnessed an overdose did not know the person. Only a minority (13%) had witnessed a close friend overdosing.

Those who had witnessed an overdose were more likely to report using drug checking services.

In the initial analysis, participants who reported witnessing an overdose were between 2.7-5.5 times more likely to use services. After the researchers controlled for the potentially confounding variables, those who had witnessed an overdose were still between 1.6-3.5 times more likely to have their supply checked. Those who reported daily injection drug use in the past six months or use of drugs that contained fentanyl were also more likely to have their supply checked.

WHAT ARE THE IMPLICATIONS OF THE STUDY FINDINGS?

In this study, the authors found that witnessing an overdose was associated with increased use of drug-checking services among people who use drugs. Very few people in the overall sample reported using these services, despite being readily available in their local community. Previous surveys of people who use drugs have shown that there is strong interest in knowing whether and how much fentanyl is present in supplies. These surveys also suggested that users were likely to change whether or how much they used in response to confirmation that their supply contained fentanyl. Other research has shown that fentanyl is now present in most of the samples tested, highlighting the value of drug checking in reducing overdose risk at the individual level and number of overdoses and overdose deaths in the population. It is possible that certain barriers to using these services are driving the disconnect between reported intentions and the actual behavior reported in this study. Research on barriers to using drug checking highlights concerns about legality and trust in the organization offering the services, and indeed legality continues to be a barrier to offering certain types of harm reduction services. Understanding and addressing these and other barriers to using harm reduction services is a key component of the ongoing response to high rates of opioid-related overdose and death.

The authors of this study also point to the possibility that individual drug users feel “invincible” or have mixed feelings about their own death until they witness an actual overdose event. This would indicate that witnessing an overdose is a key moment in which drug users experience a “wake-up call”, observing first-hand the real risks of the current drug supply, and providers could encourage and support the use of harm reduction services like drug checking.

However, since it would be ideal to try to increase service use before someone has witnessed an overdose, interventions which target similar processes are worth considering. The Health Belief Model is a psychological framework that identifies a number of factors thought to motivate health-related behaviors. These include perceptions of seriousness and personal susceptibility, perceived benefits and barriers of an intervention, “cues to action” which serve as initial motivators, and self-efficacy for accessing a service or changing one’s behavior. While many of these are likely activated by witnessing an OD, and perceived benefits of drug-checking services are well documented, it may be possible to also use this framework to develop interventions which create a similar sense of urgency without having to witness an overdose.

Motivational interviewing is a therapeutic strategy that emphasizes a nonjudgmental, supportive approach to changing drug use and other behaviors. Previous research has suggested it can lead to behavior change after critical events, such as reducing overdose risk behaviors when offered during an emergency department admission. Typically geared towards supporting reduction or cessation of substance use, this nonjudgmental strategy may also be effective for increasing motivation to use drug checking and other harm reduction services after experiences, like witnessing an overdose, which drive home the benefits of harm reduction.

LIMITATIONS

1. This study was cross-sectional, meaning that the researchers asked participants at the same time about their experience witnessing overdose and using drug checking services over the past 6 months. While the researchers are suggesting that witnessing an overdose caused greater subsequent use of drug checking services, it may also be the case that some in the sample used drug checking services before they witnessed an overdose.
2. The availability of harm reduction services varies widely across the U.S. and Canada, and regional variation in related factors such as trust in public services among people who use drugs, may also limit the relevance of these findings for other communities.

BOTTOM LINE

CITATIONS

Beaulieu, T., Hayashi, K., Nosova, E., Milloy, M. J., DeBeck, K., Wood, E., … & Ti, L. (2020). Effect of witnessing an overdose on the use of drug checking services among people who use illicit drugs in Vancouver, Canada. The American Journal of Drug and Alcohol Abuse, 1-6, [Epub ahead of print]. doi: 10.1080/00952990.2019.1708087