INTRODUCTION

From 1999 to 2017, nearly 400,000 Americans have died from an opioid overdose (Scholl et al., 2018). As a result, several legislations to reduce the morbidity and mortality associated with opioid overdoses have been passed. One piece of legislation that has grown in popularity is training in the use of naloxone to law enforcement officers (LEOs) as first responders. Because LEOs are often the first responders to arrive at the scene of an overdose, particularly in rural areas (Davis et al., 2015), it is imperative that they be trained to administer naloxone and be provided with naloxone. The 2019 National Drug Control Strategy report issued by the Office of National Drug Control Policy states that "[horizontal ellipsis]all law enforcement personnel in the United States be equipped with naloxone, model legislation be provided to states to allow naloxone dispensing via standing orders, and Good Samaritan laws be enacted to empower the public to provide help" (p. 9).

Prior studies have shown that the administration of intranasal naloxone by LEOs has been associated with reduction in opioid mortality (Rando et al., 2015). Naloxone training increases overdose knowledge and competency, and LEOs have positive attitudes toward naloxone training (Purviance et al., 2017; Ray et al., 2015; Wagner et al., 2016). However, limited studies examine LEOs' experiences with naloxone after receiving overdose prevention training.

Wagner et al. (2016) interviewed only four LEOs who had used naloxone in response to opioid overdoses. The LEOs perceived their training was adequate and, moreover, that assembling and administering intranasal naloxone was simple. In addition, their experiences after a naloxone reversal changed LEOs' attitudes or opinions about drug users, and the LEOs reported favorable reaction from community members who witnessed the LEOs' response to the overdose (Wagner et al., 2016).

To further explore LEOs' perceptions about naloxone training and administration in the field, we sought to understand LEOs' pre- and post-naloxone-training attitudes and behaviors, how LEOs' experiences of saving a life influenced their perceptions about drug users and addiction, and what should be included in the naloxone training curriculum for LEOs. Gaining a better understanding of LEOs' experiences and perceptions regarding naloxone could assist in the development of relevant training materials tailored to LEOs.

MATERIALS AND METHODS

Study Design

A descriptive study was employed to explore the perceptions of LEOs about using naloxone in the field and to identify areas that should be included in future naloxone trainings. A brief demographic survey that also included number of years as an LEO, number of times naloxone was used in the field, and if the LEO had a close friend or family with drug addiction was inquired. Interview data were obtained through face-to-face interviews using a semistructured interview guide with a convenience sample of LEOs. Institutional review board approval was obtained from the University of Michigan.

Sample and Setting

We used a purposive sampling strategy to recruit LEOs (N = 14) who (a) received naloxone training the prior year and (b) had successfully used naloxone at least once in the field after naloxone training. All the participants were recruited from one suburban, Midwestern law enforcement agency that serves a population of over 350,000 residents across 25 local units of government. The LEOs were trained by the first author in August 2015.

Data Collection and Analysis

From August 2016 to October 2016, each LEO was interviewed face-to-face in a private room at the LEO agency by a master's-prepared research assistant. Interviews were audio-recorded. Topics included (a) prior thoughts about naloxone, (b) helpfulness of training topics and delivery format, (c) LEOs' experiences when responding to an overdose and using naloxone, (d) effect of saving a life, and (e) other tips for future trainings. The interviews lasted from 30 minutes to 1 hour. Before each interview, the research assistant reviewed the study purpose and the confidentiality statement and obtained informed consent from each participant. After the interview, demographic data were collected and participants were given $30 compensation. Participants were recruited and interviewed until data saturation was reached.

Descriptive statistical analyses were performed. Demographic survey statistics was analyzed using SPSS v26. Interview data were analyzed using content analysis, which allows for categories and themes to emerge from the data (Hsieh & Shannon, 2005). The primary (C. H. D.) and secondary (J. G.) authors read all the transcripts repeatedly to achieve immersion and to gain a comprehensive understanding of the data. Next, each line of transcript was read word for word with text highlighted to capture initial thoughts and impressions. This iterative process was repeated until the initial overarching themes emerged, and then codes for subthemes were developed for each theme. Series of meetings with the first and second authors were conducted to establish consensus with the themes and subthemes. Discrepancies were resolved through consensus. The third author (C. B.) was involved in the conception of the study design, drafting the article, and critical review of the article.

RESULTS

Participant Characteristics

Most of the participants were male (n = 11, 78.6%) with a mean age of 38.5 years (SD = 9.7) and had a close friend or family member with a history of any type of addiction (n = 11, 78.6%). The mean number of years as an LEO was 9.5 (SD = 9.1; range: 1-27), and most of the LEOs used naloxone 1-2 times (n = 11, 78.6%).

LEOs reported four major themes: (a) changes in attitudes and beliefs about naloxone after receiving training, (b) feelings of goodwill after a save, (c) key teaching topics to include in training, and (d) postoverdose response strategies.

Changes in Attitudes and Beliefs About Naloxone After Receiving Training

After naloxone training, the LEOs had changed their attitudes about naloxone, were ready to respond, and had a greater sense of duty. Initially, LEOs believed that naloxone delivery was outside their role as an officer and were against the idea of being equipped with naloxone before the training. However, after the training, most of the LEOs (n = 9) had changes in their attitudes regarding naloxone. As participants shared,

I think, it is a good tool. I mean, now, I think it is a good tool. Before, like I said, I was completely against using it, that it wasn't our role.

Before, I really thought there was nothing we could do. But, when naloxone was introduced, it changed my thought.

Furthermore, this sentiment was even more pronounced after a save, as it heightened their sense of duty (n = 5),

It makes you feel good. That you did something good. But, it's work. It's my job, I feel. It's my job to protect and serve.

Another LEO shared,

But, you know, it's not my place to say, uh, you know, "You overdosed. This is the third time I've done it, and, you know-my job is to save ya." You know, first and foremost, we're peace officers, and we're lifesavers, more than we are busters. Especially me and my-where I'm at in my career. Bustin' days are over. It's time to help people, you know?

The LEOs (n = 10) saw using naloxone as their role because they were often the first responders to arrive at the scene of an overdose and being equipped with naloxone helped them to be ready to respond.

I'm a hundred percent for naloxone. The training's great and I'm glad that other officers and deputies are carrying naloxone. Cause, like I said, we are the first responders. We are the first ones to get there. It just seems meaningless when I'm standing there and available to administer it myself.

Being ready to respond was displayed by the LEO's thoughts and behaviors.

Well I always hope that I'm never gonna use it again, but I keep, I make sure that I have it with me every day. Umm, it is one of them things that you don't want to be without. It's the thing that I put at the top of my bag so I don't even have to dig in my bag.

Another officer clearly stated the importance of being equipped with naloxone,

So, I think, sometimes we are first on scene, and it's better to have it and not need it, than need it and not have it.

Feelings of Goodwill After a Save

All LEOs (N = 14) unanimously reported feelings of gratification about saving the lives of those who had overdosed. Many of the LEOs (n = 7) discussed the family and friends of the person who overdosed and found their interactions with them to be meaningful. LEOs expressed that the gratitude of the loved ones of the naloxone recipient who overdosed was highly fulfilling and that giving the lives of those who had overdosed back to their loved ones was significant. As one officer stated,

Everything was in the training. Ya know, other than the, the feeling of an accomplishment or the good deed that you did for the day. Umm, and I don't even know, umm, we don't even talk about that, but that's what they should know. That there is something positive on a save.

Other LEOs shared similar sentiments,

The biggest draw I've taken is the gratification from loved ones.

It's always a good feeling when you do something good. A lot of times we deal with a lot of negativity. We go to a lot of bad houses. Deal with a lot of bad people that do a lot of bad things to women and children. And, ya know, to be able to save someone's life and know that there is hope for them. They're gonna live another day and all their children are, they're gonna be around for their children, it's, umm, it's a nice feeling.

I believe his wife or fiance was eight or nine months pregnant, and in my mind, when I saw that bedroom I saw, umm, a crib and I saw pink clothing and a pink bracelet, okay, I have to do whatever I can to save this, this gentleman.

Couple LEOs (n = 2) also described the feeling that God had put them there for a reason to save someone's life using naloxone.

So for him at that time in his life, he needed someone to help his brother, and I just felt that God put me there for a reason.

Teaching Topics That Extend Beyond the Standard Naloxone Curriculum

The LEOs received a naloxone curriculum that consisted of myths and facts about naloxone, signs and symptoms of overdose, legislation on overdose prevention laws, how to respond to an overdose, and documentation instructions postoverdose. In addition, the LEOs heard a testimony of a person who was in long-term recovery (Dahlem et al., 2017). Although our naloxone curriculum went beyond the standard curriculum by discussing myths and facts and having a person in long term share their testimony, the results from this study identified that the LEOs would benefit from additional education regarding the (a) stigma of addiction, (b) clarifying misconceptions, and (c) instilling hope for recovery despite repeat saves.

Many LEOs (n = 9) expressed the behaviors of person who use drug resulted from choices that could have been avoided.

[horizontal ellipsis]but it (addiction) is also their choice, too. Umm, their choice to use the drugs. Their choice to seek treatment and their choice to stay with treatment and their choice to say no when that chance comes back around...

[horizontal ellipsis]they do put themselves in their shoes and they don't get the consequences of their actions.

Despite the misunderstanding about the disease of addiction, its effects on the brain, and how the changes in the brain influence behavior, other officers emphasized the importance of identifying the person underneath the disease of addiction.

I think over all, I think we just need to remember that they are people. Ya know, and they're fighting a, an addiction.

I never judge someone on their situation. So, I don't know what she was going through.... I want to help you get through that hump you're trying to get over. So whatever I can do to help you, I want to do it. Naloxone is that push. It's a step.

In addition, some LEOs (n = 8) had misconceptions about naloxone and a concern that naloxone would encourage riskier drug use:

So, they know we have it. We'll get there a lot quicker. So, I feel like the concern is still, but some people may push the boundaries even more cause they know we'll be there quick.

Others experienced discouragement when encountering repeat overdoses:

We've had individuals who've been saved by naloxone multiple times, which that, that's a little disheartening. Ya know, cause like you think you get a second chance, then they get a third chance, and a fourth chance and it's like, come on, ya gotta turn this around here.

Despite these misconceptions and discouragements, most of the LEOs (n = 11) knew that naloxone would give individuals another opportunity for recovery:

I'm for it, ya know. Oh, I mean, like I say, if it could save somebody's life and give them another day with their family, ya know, it's worth it. Umm, that's a very optimistic view, but still, ya never know, that one person, may save 'em. May save their life. May change their life over.

You can only hope that, ya know, they take advantage of that second chance and, and make some changes.

Postoverdose Response Strategies

The naloxone training prepared LEOs to rescue, but it did not provide information for the LEOs in how to approach the overdose survivors and their loved ones after a reversal. Some LEOs reported that, after waking up, many people who overdosed are fearful of legal prosecution. In fact, several LEOs (n = 5) said that an unexpected benefit to administrating naloxone is that, once conscious, individuals who overdosed often provide useful information on who their drug dealer is and how they fit into the drug trade system. This information may allow LEOs to prevent future overdoses and interrupt the illegal distribution of opioids. Some LEOs (n = 5) said that family and friends also give helpful information relevant to what the drug is and where it came from. Other LEOs (n = 3) shared that their role in resuscitation was not so much prosecution as helping the person who overdosed recover by getting them to a hospital, not to jail.

The person that they focus on is the police. Cause they think; "I just used an illegal drug so I'm going to jail." And that's not the case. We're here to help you.

Usually the family comes forward and close friends when it happens. And you get valuable information from it about who's dealing their and where they're getting stuff and who else is using stuff like that.

Nobody wanted really to come forth and give us any, ya know, important information that would help us access the patient better.

Other LEOs (n = 3) expressed the need to have additional follow-up strategies for people who overdosed as well as feedback information on the person rescued.

I'm just kind of brainstorming here, but, you know, we may be able to have-something like one particular deputy that kind of follows up. Maybe we have, like, an outreach person.

There's very few rewards in this job. It makes you feel good, however, you always wonder. What, my question now is, what has happened with her? Did it affect her in a positive way where she realized; I need help? I don't ever want to be in that position again.

DISCUSSION

Our study showed that LEOs changed their attitudes and beliefs toward naloxone administration after receiving training and after experiencing a successful resuscitation. In addition, LEOs experienced feelings of fulfillment from being able to save lives by delivering naloxone. Future naloxone curriculum could benefit from additional content on the stigma of addiction, the disease process of addiction, clarifying misconceptions about naloxone, instilling hope of recovery, and strategies for postoverdose responses.

Similar to Green et al.'s (2013) findings, the LEOs in our study also felt a sense of duty to respond to overdoses but had concerns about carrying naloxone. At the time of Green et al.'s study, LEOs were not equipped with naloxone. In our study, the local county sheriff required naloxone training for all deputies. It was clear that many LEOs were still not in favor of carrying naloxone before the training. However, after receiving the naloxone training and particularly using the naloxone in the field, all the officers had a change of view and attitude toward their role in overdose prevention. This suggests that the officers' sense of duty to their job requirements superseded any initial negative sentiments and, once enacted, the officers had a favorable shift in perspective. In fact, since the training, this current agency have had over 200 reversals.

Other studies also reported support of LEOs' positive attitudes toward naloxone training (Purviance et al., 2017; Ray et al., 2015). The results strongly supported that naloxone trainings were effective in changing the attitudes and beliefs of LEOs regarding the use of naloxone. As LEOs were often the first responders to arrive at the scene of an overdose, equipping and training LEOs to carry and administer naloxone was found to be an important opioid overdose prevention strategy (Davis et al., 2015) and was shown to be cost-effective (Townsend et al., 2020). Despite the substantial support of training LEOs to carry naloxone, the 2017 Police Executive Research Forum (PERF) survey of over 275 police chiefs across the nation showed that 63% of responding police agencies have trained officers to carry naloxone (PERF, 2017).

Feelings of goodwill, helping family and their friends, and experiencing a greater sense of purpose were positive outcomes after using naloxone. A term in the literature to describe this sense of work fulfillment has been referred to as compassion satisfaction. Compassion satisfaction describes the "positive aspects of working in helping professions" (Turgoose et al., 2017) in which people in caring professions gain satisfaction in making a difference in the lives of others (Figley & Stamm, 1996). In a recent exploratory study, compassion satisfaction was significantly correlated with less burnout and secondary traumatic stress among police officers (Grant et al., 2019). Our exploratory descriptive study showed that every LEO had shared the significance of saving a life and the impact it had on how they felt about themselves and their job. Future research can assess the relationships among compassion satisfaction associated with naloxone rescues, levels of burnout, and LEOs' perceptions about addiction and people who use drugs.

Although this group of LEOs were one of the first agencies trained in the state, the results of interviews highlight the need for further officer education on the disease of addiction, including the hope of recovery, and naloxone misperceptions. Evidence clearly indicates how addiction is a complex disease of the brain that results in changes in reward circuitry of a person's brain (Volkow et al., 2016). Thus, recovery is not solely based on an individual's choice to seek treatment or lack of willpower to stop using drugs. Efforts should be made to counteract this stigmatization by educating LEOs about addiction and encourage their tendencies to humanize, and support drug users, seeing resuscitation with naloxone as the first step along their path to recovery. Furthermore, greater understanding and knowledge about the disease of addiction could alleviate misperceptions and stigma surrounding addiction for police officers. In the mental health literature, studies have shown how the Crisis Intervention Team training with police officers has shown to reduce officers' social distance with people experiencing mental health and substance use disorders (Bahora et al., 2008) and shown improvements in officers' knowledge, attitudes, and skills in interacting people with mental health disorders (Compton et al., 2014). Future studies could develop and evaluate a comprehensive, tailored, and interactive curriculum on addiction for police officers.

Other topics that would be helpful to include in future trainings would be to implement a referral pathway to provide ongoing postoverdose support for individuals who have been revived with naloxone. Creating a coordinated system-wide continuum of care for overdose survivors is much needed. There has been a burgeoning of postoverdose response strategies that are being developed and implemented (Formica et al., 2018). In fact, our promising model of using peer recovery support specialists and case management navigators in the emergency departments postoverdose has shown that 34.4% of the people who engages with the Recovery Opioid Overdose Team receive some form of substance use treatment (Dahlem et al., 2019). Another police-led intervention, the Law Enforcement Assisted Diversion (LEAD), was developed to build police-community relations and emphasize harm reduction interventions. The LEAD program was shown to have positive effects on arrests and reductions in recidivism for participants compared with non-LEAD participants (Collins et al., 2017).

Although the LEOs in our study had mixed feelings regarding how freely the bystanders and overdose survivors shared their information, it would be important to emphasize in future trainings in an overdose situation that it is not a criminal investigation, but of medical health emergency. Fear of arrest for witnesses and for the victim because of outstanding warrants has been well cited in the literature for people not calling 911 for an overdose despite legislation of Good Samaritan laws (Koester et al., 2017; Latimore & Bergstein, 2017; Selfridge et al., 2020). A recent study by Wagner et al. (2019) showed that participants perceived calling 911 was synonymous with "calling the cops" and purports for the development of patient-centered postoverdose interventions such as an alternative number for overdose interventions without "triggering a law enforcement."

Our study has several limitations. As this was an exploratory descriptive study with a limited sample in one geographic location, the results cannot be generalized to other areas or other law enforcement agencies. In addition, the results were obtained in 2016 at a time where first responders being equipped with naloxone were relatively new. LEOs' perceptions may have changed because of increasing support from upper-level law enforcement administration on equipping all LEOs with naloxone (Office of National Drug Control Policy, 2019; PERF, 2017) and wider acceptability of naloxone. However, despite these limitations, we believe this study provides important insights into LEOs' attitudes about naloxone and their willingness to use it.

In conclusion, our study supports that LEOs had changes in attitudes after going through naloxone training and using naloxone in the field, but the standard naloxone curriculum was not sufficient. Additional education on the disease of addiction and reducing the stigma of addiction is still needed along with postoverdose intervention strategies.

REFERENCES