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Qualitative assessment of take-home naloxone program participant and law enforcement interactions in… Deonarine, Andrew; Amlani, Ashraf; Ambrose, Graham; Buxton, Jane May 21, 2016

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RESEARCH Open AccessQualitative assessment of take-homenaloxone program participant and lawenforcement interactions in BritishColumbiaAndrew Deonarine1, Ashraf Amlani1, Graham Ambrose1,2 and Jane A. Buxton1,2*AbstractBackground: The British Columbia take-home naloxone (BCTHN) program has been in operation since 2012 andhas resulted in the successful reversal of over 581 opioid overdoses. The study aims to explore BCTHN programparticipant perspectives about the program, barriers to participants contacting emergency services (calling “911”)during an overdose, and perspectives of law enforcement officials on naloxone administration by police officers.Methods: Two focus groups and four individual interviews were conducted with BCTHN program participants;interviews with two law enforcement officials were also conducted. Qualitative analysis of all transcripts was performed.Results: Positive themes about the BCTHN program from participants included easy to understand training, correctingmisperceptions in the community, and positive interactions with emergency services. Potential barriers to contactingemergency services during an overdose include concerns about being arrested for outstanding warrants or for otherillegal activities (such as drug possession) and confiscation of kits. Law enforcement officials noted that warrants werecomplex situational issues, kits would normally not be confiscated, and admitted arrests for drug possession or otheractivities may not serve the public good in an overdose situation. Law enforcement officials were concerned aboutlegal liability and jurisdictional/authorization issues if naloxone administration privileges were expanded to police.Conclusions: Program participants and law enforcement officials expressed differing perspectives about warrants, kitconfiscation, and arrests. Facilitating communication between BCTHN program participants and other stakeholders mayaddress some of the confusion and remove potential barriers to further improving program outcomes. Naloxoneadministration by law enforcement would require policies to address jurisdiction/authorization and liability issues.Keywords: Naloxone, Take-home naloxone, Law enforcement, Canada, British ColumbiaBackgroundOpioid overdose due to illicit drug use and prescriptiondrugs and their associated mortality and morbidity haveemerged as a global health issue [1–4]. Globally, an esti-mated 69,000 people die each year from opioid overdose.However, data from a number of jurisdictions has indi-cated that community-based naloxone programs, whichinvolve teaching people how to recognize and respondto an opioid overdose, can reduce deaths caused by over-dose [5]. In response to these overdoses, community-based take-home naloxone (THN) programs have beendeveloped in a number of different jurisdictions includ-ing Canada, the USA, Australia, and several countries inEurope [6–11]. McAuley et al. identified 25 take-homenaloxone evaluations and found that every 3 months,there were 5.2–13.1 naloxone administrations for every100 persons trained [12], indicating the high degree ofactivity within these programs. In Canada, opioid-relatedhospital stays have increased by 40 % in the period from2006 to 2011, making opioids the second-most signifi-cant drug category responsible for hospital resource* Correspondence: jane.buxton@bccdc.ca1School of Population and Public Health, University of British Columbia, 2206East Mall, Vancouver, BCV6T 1Z3Canada2BC Centre for Disease Control, 655 West 12th Avenue, Vancouver, BCV5Z4R4Canada© 2016 Deonarine et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, andreproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link tothe Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Deonarine et al. Harm Reduction Journal  (2016) 13:17 DOI 10.1186/s12954-016-0106-1consumption [13], and there have been published evalu-ations of THN programs in Vancouver [14], Edmonton[15], and Toronto [16]. In addition to THN programs,several jurisdictions have expanded naloxone programsto law enforcement officials, since they are often the firston the scene during an overdose. There are hundreds ofpolice departments now administering naloxone acrossthe USA. According to the North Carolina Harm Reduc-tion Coalition, 654 police departments have naloxoneprograms across 30 states [17], with the largest numberof police departments being located in New York (193),New Jersey (130), and Illinois (58).The British Columbia take-home naloxone (BCTHN)program was developed by the British Columbia Centrefor Disease Control (BCCDC) and initiated in 2012 [18].At participating community sites, clients are trained torecognize and respond to an overdose and are providedwith a naloxone kit (details about the program are avail-able from the program website http://www.towardtheheart.com as of April 14, 2016, there are 178 locationswithin BC that dispense naloxone as part of the BCTHNprogram and 581 overdose reversals with naloxone havebeen reported, 7416 people have been trained, and 7418people received naloxone kits [19]. Recently, an increasein the number of overdoses associated with fentanyl hasbeen identified in BC [20, 21], creating a higher demandon the program.Feedback from the BCTHN Community AdvisoryBoard, consisting of THN site coordinators and peoplewho use drugs, have identified some potential concernsrelated to interactions between program participants andlaw enforcement. In particular, it was noted fromBCTHN records that despite an increased emphasis tocall emergency services (calling “911”), nearly a third ofthose who administered naloxone (herein referred to as“BCTHN naloxone administrators”) did not call 911[18]. This qualitative evaluation of the BCTHN programwas performed to explore participant perspectives onthe program and barriers to contacting emergency ser-vices during an overdose. Finally, potential barriers to thecreation and implementation of programs in which lawenforcement officials administer naloxone were explored.By identifying these factors, strategies and policies can beimplemented to improve THN programs within BC,throughout Canada and in other jurisdictions.MethodsEthics, consent, and permissionsEthics approval was received from the University of BritishColumbia, Interior Health, and Vancouver Coastal Healthethics boards (H12-02557). All participants provided writ-ten informed consent before interviews or focus groupswere conducted, and all identifiers were removed from thetranscripts.Study settingThe BCTHN program is operated by the BCCDC HarmReduction Program, which develops training materials;is responsible for enrolling sites (i.e., community agen-cies or health units that partner with health care pro-viders); and distributes naloxone kits to the sites.Enrolled community sites provide training to clientsabout overdose prevention, recognition, and responseand dispense naloxone kits to eligible individuals. Sitesreport administrative data to BCCDC who also collectsdetails about naloxone administration. BCTHN siteswere used to recruit study participants.Study designA qualitative methodology was selected to explore per-ceptions, practices, and group dynamics that might con-tribute to the apprehension of calling 911. The studyconsisted of focus groups conducted with harm reduc-tion clients who had received program training, key in-formant interviews with experienced BCTHN naloxoneadministrators, and law enforcement officials. Semi-structured interview guides were adapted from a priorevaluation (by Banjo et al. [14]). In the interview guides,the questions were designed to explore perceptions re-lating to program training, naloxone administration andoverdose response, and attitudes and awareness sur-rounding the program. These questions were pilotedwith three people who use opioids in Vancouver. Add-itionally, questions were created to understand the per-ceptions that law enforcement officers had about theprogram, barriers to implementation, community aware-ness and integration, and compatibility with broader lawenforcement policies.Participant recruitmentProgram participants were recruited from THN siteswithin the Vancouver Coastal Health, Fraser Health, andInterior Health regions. Focus group participants whoused opioids, had received program training, and whowere at least 19 years old were eligible to participate inthe study. Additionally, client key informants must haveadministered naloxone at least three times. All clientswho participated were provided with a $10 honorariumfor their time. Law enforcement participants were re-cruited by reaching out to existing contacts within twopolice departments.Data collection and analysisFocus groups and individual interviews with BCTHNnaloxone administrators and law enforcement officialstook place between April and June 2015. One investigator(GA) conducted individual interviews and focus groups inperson and by phone. The interviewer was not otherwiseinvolved in the BCTHN program. Additionally, researchDeonarine et al. Harm Reduction Journal  (2016) 13:17 Page 2 of 8assistants were present at the focus groups to assist in thecollection of demographic information, to record notesconcerning group dynamics and other observable infor-mation, and to remunerate participants who left early toavoid disruption of the focus group. Focus groups and in-terviews took approximately 1 h to complete and weredigitally recorded and transcribed verbatim. Paraphrasedexamples of questions posed in the semi-structured inter-view include “Did you ever have your naloxone kit confis-cated?” or “How did you find out about the trainingsessions?”Transcripts were anonymized by removing identifyinginformation and imported into NVivo 10 for analysis.All the authors reviewed the transcripts independentlyto identify codes for qualitative analysis; the codes werediscussed and agreed upon through consensus andthemes were developed using a grounded theory ap-proach [22]. Using a content analysis and qualitative de-scriptive approach (a low-inference analytic method[23]), the themes were then identified in the transcripts.This approach identified information that can be de-scribed as “straight and largely unadorned” which can beused for policy development and by practitioners tomodify their practice [24]. Other researchers (JAB, AA,GA) reviewed the themes, and differences in opinionwere resolved. Member checking with two of the partici-pants was performed to assess the descriptive and inter-pretive validity of the analysis.ResultsParticipant demographicsTwo focus groups involving eight BCTHN program cli-ents each and four individual interviews with BCTHNnaloxone administrators were conducted for a total of20 client interviewees (Table 1). Two individual inter-views were performed with law enforcement officialsfrom BC, one from the Vancouver Police Departmentand a Royal Canadian Mounted Police officer fromNanaimo.The study participants (including BCTHN programparticipants and police officers) were recruited fromvarious locations in southern British Columbia (seeFig. 1): 10 were from Vancouver and 10 from Surrey(large urban centers) and one from both Vernon andNanaimo (smaller communities). The interviews in Vernonand Nanaimo were by phone; all other study participantsincluding the focus groups were interviewed in person.General themes from program participantsProgram participants expressed positive perspectivesabout the THN program including the ability to savelives, the understandable nature of the educationalcontent, its accessibility to those with limited readingskills, and integration into the community (see Table 2).Additionally, emergency services were perceived to bevery supportive of program participants. One particularbenefit that emerged was the correction of false percep-tions about naloxone by program participants.Arrest warrants and naloxone kit confiscationBCTHN program participants noted a general concernabout being arrested if they called for emergency assist-ance and law enforcement attended. Police were notedto collect names of those present at the overdose sceneand check if they had outstanding arrest warrants. Bothlaw enforcement officials also commented on the issueof warrants, noting that they are aware that it contrib-utes to the apprehension felt by some individuals wheninteracting with the police (Table 3). Law enforcementinterviewees also noted that if they observed largeamounts of illegal substances in someone’s home, wherean overdose had occurred, they would be obliged to actsince possession of illegal substances is a criminal offense.However, they also noted that an overdose is a medicalissue and that the public good would be weighed in con-sultation with commanding officers, making the situationmore complex and nuanced.Another theme that emerged pertained to responderconcerns about kit confiscation. One intervieweeclaimed to have had their kit confiscated while othersdenied issues with confiscation. However, it is notknown if the confiscation occurred early in the program.One law enforcement interviewee suggested that ifTable 1 Demographics of participating BCTHN program clients(n = 20)Variable ValueGenderMale 11Female 9Mean age (years)All clients 49Male 51Female 46EducationGrade 10 or less 8Grades 11–12 6Post-secondary 4Unknown 2Duration of drug use<21 years 421–30 years 631–40 years 6>40 years 2Unknown 2Deonarine et al. Harm Reduction Journal  (2016) 13:17 Page 3 of 8confiscation occurred, it was probably due to the inex-perience of the officer.Law enforcement views on police administering naloxoneContradictory views of the role of police offers regardingpotential naloxone administration were noted (Table 4).One police officer remarked that law enforcement use ofnaloxone could impinge on the responsibility of otheremergency services. However, the other officer notedthat ensuring that lives are saved is a shared responsibil-ity of all emergency services, including the police.Another theme for law enforcement was that of liabil-ity. One law enforcement interviewee noted that liabilitywas an important issue with respect to police adminis-tering naloxone in overdose cases (see Table 5).Additionally, a law enforcement officer articulatedconcerns about administering naloxone, centeringaround understanding medical issues and using a nee-dle (see Table 6).DiscussionCommon themes about naloxone administration wereidentified from the BCTHN interviewees. The participantsprovided generally positive perceptions of the BCTHNprogram, including positive interactions with the first re-sponders. Three factors were suggested to play a role inBCTHN naloxone administrator reluctance to contactemergency services, namely, (1) outstanding warrants; (2)being arrested for illegal activities, such as possession ofdrugs and breach of conditions of probation; and (3) kitFig. 1 Map of British Columbia showing sites from where the study participants were recruitedDeonarine et al. Harm Reduction Journal  (2016) 13:17 Page 4 of 8confiscation. We identified no differences in the themesfrom rural versus urban interviewees.From the interviews with law enforcement officers, aset of complementary themes was identified. For in-stance, the police officers noted that while they are re-quired to enforce the law and pursue individuals foroutstanding warrants, it can depend on the context.Additionally, the law enforcement officials interviewednoted that in general they would not confiscate naloxonekits in contradiction to the assumptions of some of theBCTHN program participants. The participants’ concernregarding being arrested was contradicted by the infor-mation provided by law enforcement: it is often a morenuanced situation in which an officer will consult with acommanding official and weigh the medical and publicgood of pursuing an arrest in the context of the situ-ation. Communicating to BCTHN naloxone administra-tors that Vancouver Police Department members do notroutinely attend the overdose scenes may address someconcerns. Revisiting the general police policy of record-ing the names of all present at the overdose scene to de-termine if there are outstanding warrants would helpallay fears of arrest. While there are rare instances inwhich an arrest is required (such as during the case ofan assault occurring at the site of an overdose), clearpolicies outlining when arrests may or may not occur inkey scenarios may help law enforcement officials andBCTHN program participants navigate the legal, ethical,and safety issues that can occur during an overdose.Interestingly, the themes in Table 3 illustrate that theBCTHN program participants and law enforcement offi-cers have differing perspectives on warrants, arrests, andresponder concerns with respect to naloxone kit confis-cation. One reason for these contradictory opinions maybe due to information silos within the BCTHN programparticipants and other stakeholders such as law enforce-ment and historic distrust. Hence, clearer lines of com-munication between program participants and lawenforcement could provide significant benefits to theTHN program where police could directly dispel falsenotions and address concerns. Educational efforts withinthe BCTHN program potentially involving participationby law enforcement community liaisons could help allayfears that program participants have and strengthen thecapacity of the program to successfully treat overdoses.While the law enforcement officials noted that therewere major benefits to police administering naloxone,the role of police officers with respect to other first re-sponders emerged as a potential issue of contention.However, the difference in opinion noted in Table 4could be due to each law enforcement officer being froma different department. A major concern identified by aninterviewee was that of liability and the legal conse-quences an officer might expose themselves to if theywere involved in naloxone administration. Concernsaround a lack of intranasal delivery (which is used insome jurisdictions in the USA) and about needle deliverywere also noted (see Table 6). Clear policies around jur-isdiction, interactions with first responders, and also li-ability would need to be addressed. Davis et al.systematically reviewed the legal issues around liabilityand authorization with respect to naloxone administra-tion by law enforcement officials. In this study, no offi-cers were sued for administering naloxone, and “GoodSamaritan” policies were found to be important in theTable 2 General themes that emerged from focus groups andinterviews with BCTHN naloxone administratorsTheme ExampleSaving lives in the community “Well we were in an environmentwhere there [were] a lot of lives to besaved so we found it quite beneficial.”- Focus group 1 participant #5Simple to understandeducational content“Everything was right to the point,what we needed to know and how touse the Narcan kit and how to use,how to open this little bottle withoutgetting cut by your, on your fingerswhen you open it. So everything wasuseful in the training.”- Focus group 2 participant #1Accessibility to people withlimited reading skills/illiteracy“I have problems reading, I am dyslexic.People I know that but, the sessionitself was really informative and sheread it to us and she pointed to it asshe was reading it and like explainedhow to do it, take care of it, physicallyhow, because that’s how I learn thingstoo is by visual.”- Focus group 2 participant #5Integration into thecommunity“Round here, most people know whohas it usually or they just yell out right,if someone needs it, they just yell outwho’s got a kit, right?”- Focus group 1 participant #5Positive interaction withemergency responders“I called 911 twice and this was atwork, at [agency name]. I naloxonedthe one girl and the ambulance cameand [said] I did good. And then thesecond time the police and ambulancecame and I did good again, had themall up and ready and they’re like didyou do healthcare and I’m like no, Ijust learned, I’m a self-learner.”- Client interviewee 2Correcting misperceptionsabout naloxone“But people generally are, they acceptit with open, with an open mindbecause – but you know what hasmisled a lot of people is that moviePulp Fiction…. Where Buddy gets theadrenalin shot in the heart eh, andpeople are under themisunderstanding that that wasNaloxone or Narcan. So I’vestraightened quite a few people outthat have seen that movie.”- Client interviewee 1Deonarine et al. Harm Reduction Journal  (2016) 13:17 Page 5 of 8successful implementation of law enforcement programs[25] which addressed issues of liability and jurisdiction.A recent report on the establishment of a naloxone pro-gram for prisoners in New York noted that a key aspectto acceptance of the program among parole officers andcorrections staff (who are now being trained for naloxoneadministration) was understanding the need for naloxonein the community [26]. Establishment of such a programin BC could help achieve the three recommendationsmade recently by the office of the chief coroner, whichconsisted of removing barriers to immediate medical as-sistance after an overdose, raising awareness of the im-portance of immediate medical attention, and supportingoverdose-related interagency learning [27].Limitations of this study include the potentially limitedrepresentativeness of the interviewees, who are predomin-antly older, long-term drug users (>20 years). Additionally,convenience sampling was used to recruit intervieweeswhich may also make the opinions, themes, and otherobservations not representative of the program partici-pants as a whole. The researchers involved in the quali-tative analysis process attempted to provide an unbiasedTable 3 THN program participant and law enforcement official perspectives on the themes of warrants, kit confiscation, and arrestsTheme THN participants Law enforcement officialsExercising arrestwarrants“Right away he bolted because he thought 911 had beencalled and he might have had a warrant and that’s theirbiggest fear right, they don’t want the police involved.Ambulance, they’re not, they’re not so, it doesn’t matter somuch about the ambulance, like they’ll go to the hospital ifthe ambulance is there. If it’s not there don’t bother, I’malive now.”- Client interviewee 1“Typically if we go to an overdose call, it, the fact thatsomebody’s overdosed doesn’t give us a right in order wejust search everybody in the vicinity. I mean really ourprimary responsibility of this call is to preserve the life ofsomebody that’s overdosed (right). I, my experience is thatthe people that are around aren’t necessarily in any peril. Imean we do have to know the last names, etcetera andreally unless somebody there happens to have a warrant fortheir arrest, well I don’t in my experience know that otherpeople that are at the scene are being searched or arrestedor detained, or you know unless there’s some reasonableground that you know that it was you know forcefullyadministered or you know or anything else they had. Imean that is such a rarity.”- Law enforcement interviewee 2Arrest for illegal activity(possession, breach ofprobation, etc.)“Yeah, police because then like what were you doing whenyou were coming, what are you doing in this area or wereyou buying drugs too, so then what if I get in trouble andthey start questioning me and them I’m involved for givingher the naloxone, the person the naloxone, and I’m like shit,I was just walking by trying to save a life.”- Client interviewee 2“But generally, if it’s a medical call, like if, like that’ll, I believethat’ll get fire and ambulance, ambulance for sure, butusually fire tags along for anything. But they’ll go and then Iguess if there’s a dangerous circumstance, they’ll call policeto assist. What you hear often over police radio isambulance is attending for an overdose, police [aren’t?]required, just so you’re aware, and then a Sergeant will go,okay, and then that’ll be that, no one’ll go because it’s, it’skind of fallen now into the realm that even though thedrug that was used was illegal, it’s a medical call becausewhere they’re at now is medical…”- Law enforcement interviewee 1Responder concerns andkit confiscation“… the first responders showed up and there was, I believeit was an ambulance or a fire, but the guy started yelling atme ‘cause I had the needle in my hand, so I just yelled backat him, for like you know I’m totally, it’s legal for me to havethis, why are you mad? Because you can’t carry it? Youknow so that was probably maybe twice in a situation likethat where I‘ve had first responders you know say shit likethat to me. Otherwise, nobody’s said anything.”- Client interviewee 4“I would probably say that if that’s [kit confiscation]happened, it would probably be inexperience of an officer. Imean the Naloxone kits are given by prescription so theycan have them, I mean they have no, people can’t get highoff them. … I mean we have no business taking thosethings, that’s those are all measures to preserve their lifeand health.”- Law enforcement interviewee 2Table 4 Opposing views on the possible role that policeofficers can play concerning naloxone administration“My concern would be that if it’s given to the police, you’re kind ofgetting into that quasi-territory of cross-training which I know hasn’talways been successful, such as like are you a police officer or you’re aparamedic because generally, [our police officers] rely heavily on theirco-relationship with EHS [Emergency Health Services] so if like policeofficers were to carry kits…”- Law enforcement interviewee 1“I think the primary mandate, or responsibility of police is to protectpublic safety and preserve life, and I think that’s a primary role of everyemergency responder and I don’t think that police or firefighters or[ambulance] bicker or compete over those roles. We all have thatresponsibility.”- Law enforcement interviewee 2Table 5 Potential concerns about liability discussed by a lawenforcement official“I can see a plethora of issues arising, primarily to do with liability … Youknow I, the liability issue, in all honesty, that’s I’m sure someone’ll workthat out. I’m a, I’m a lowly patrol constable so at that level I could see itbeing beneficial. … And we’ve recently started carrying tourniquets andyou know is there medical concerns if we administer the [inaudible],we’re acting in good faith so you get that kind of pass all.”- Law enforcement interviewee 1Deonarine et al. Harm Reduction Journal  (2016) 13:17 Page 6 of 8appraisal of themes and opinions expressed during theinterview process. Despite member checking, the rolethat some of the researchers played in the organizationssupporting BCTHN may inadvertently influence results.ConclusionsThe qualitative assessment of the BCTHN programidentified several strengths of the program and potentialconcerns that may prevent BCTHN naloxone adminis-trators from contacting emergency services during anoverdose, such being arrested for outstanding warrantsand illegal activity, and respondent concerns about kitconfiscation. Instituting clear lines of communicationbetween THN participants and law enforcement withguidelines concerning warrants and kit confiscationscould help address issues identified by both parties.With respect to naloxone administration by the police,law enforcement officials identified the issues of liabil-ity and jurisdiction/authorization as potential barriers.Based on experience in other jurisdictions especially inthe USA, implementing “Good Samaritan” regulationsand educational programs emphasizing the benefits ofnaloxone to the community could be instrumental forsuch programs going forward in BC, Canada, and otherjurisdictions. Discussion and communication aboutthese changes could be facilitated through the use ofonline portals and other tools.Consent to publishIndividual data from participants were not reported,and full permission to use interviewee data (includingquotations) as outlined in the manuscript was obtained.AbbreviationsBC: British Columbia; BCCDC: British Columbia Centre for Disease Control;BCTHN: British Columbia take-home naloxone; RCMP: Royal CanadianMounted Police; THN: take-home naloxone; UBC: University of BritishColumbia.Competing interestsThe authors declare that they have no competing interests.Authors’ contributionsThe study was conceived and the study materials were developed by GA,AA, and JAB. GA coordinated participant recruitment and conducted all theinterviews and focus groups. The transcripts were reviewed by AD, GA, AA,and JAB. Qualitative analysis of the transcripts was performed by AD, and thefinal manuscript was prepared by AD with input and approval from GA, AA,and JAB. All authors read and approved the final manuscript.AcknowledgementsWe would like to thank all the participants for the time they contributed tothis investigation and would also like to acknowledge Erin Gibson, AlexScott, Griffin Russell, and Jessica Bridgeman for the assistance withparticipant recruitment, the student note takers Justin Sorge, Sonia Ishiguro,Corinne Tallon, and Zakary Zawaduk and Tom Lavery for creating the map.FundingThis study was supported by the BCCDC. AD is supported by the UBCclinician investigator program.Received: 24 February 2016 Accepted: 6 May 2016References1. Guidelines for the psychosocially assisted pharmacological treatment ofopioid dependence - PubMed - NCBI [http://www.ncbi.nlm.nih.gov/pubmed/23762965]. Accessed 14 Feb 2016.2. Caplehorn JR, Dalton MS, Haldar F, Petrenas AM, Nisbet JG. Methadonemaintenance and addicts’ risk of fatal heroin overdose. Subst Use Misuse.1996;31:177–96.3. 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Can J Public Heal. 2013;104:e200–4.Table 6 Concerns about the technicalities of naloxoneadministration“The reservations would be that because we’re big city policing, weare, ambulance is always just a moment away, so they say, so for thatwell then you’re kind of making a decision, am I going to take thismedical concern into my own hands, am I properly identifying theissue as an overdose or is the guy having a seizure and this is goingto kill him, or I can wait 30 seconds until the ambulance comes,which is fine, which is current practice. I know that generally VPDdoesn’t do too much medical, just [inaudible] the primary goal is toget EHS or ambulance there as soon as possible and some very barebones stuff, so I could see that being complicated. That’s kind of thebig decision going in [inaudible] do it now or wait the minute ‘tiltrained medical personnel can do it. I’ve never given a needle so…”- Law enforcement interviewee 1Deonarine et al. 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J Appl Behav Sci.1986;22:141–57.23. Sandelowski M. Whatever happened to qualitative description? Res NursHealth. 2000;23:334–40.24. Piper TM, Stancliff S, Rudenstine S, Sherman S, Nandi V, Clear A, Galea S.Evaluation of a naloxone distribution and administration program in NewYork City. Subst Use Misuse. 2008;43:858–70.25. Davis CS, Carr D, Southwell JK, Beletsky L. Engaging law enforcement inoverdose reversal initiatives: authorization and liability for naloxoneadministration. Am J Public Health. 2015;105:1530–7.26. Zucker H, Annucci AJ, Stancliff S, Catania H. Overdose prevention forprisoners in New York: a novel program and collaboration. Harm Reduct J.2015;12:51.27. Egilson M: Preventing death after overdose: BC Coroners Service child deathreview panel: a review of overdose deaths in youth and young adults.2009–2013. Vancouver; 2016•  We accept pre-submission inquiries •  Our selector tool helps you to find the most relevant journal•  We provide round the clock customer support •  Convenient online submission•  Thorough peer review•  Inclusion in PubMed and all major indexing services •  Maximum visibility for your researchSubmit your manuscript atwww.biomedcentral.com/submitSubmit your next manuscript to BioMed Central and we will help you at every step:Deonarine et al. Harm Reduction Journal  (2016) 13:17 Page 8 of 8


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