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Predictors of seeking emergency medical help during overdose events in a provincial naloxone distribution… Ambrose, Graham; Amlani, Ashraf; Buxton, Jane May 20, 2016

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Predictors of seeking emergencymedical help during overdose events ina provincial naloxone distributionprogramme: a retrospective analysisGraham Ambrose,1 Ashraf Amlani,1 Jane A Buxton1,2To cite: Ambrose G,Amlani A, Buxton JA.Predictors of seekingemergency medical helpduring overdose events in aprovincial naloxonedistribution programme: aretrospective analysis. BMJOpen 2016;6:e011224.doi:10.1136/bmjopen-2016-011224▸ Prepublication history forthis paper is available online.To view these files pleasevisit the journal online(http://dx.doi.org/10.1136/bmjopen-2016-011224).Received 16 February 2016Revised 19 April 2016Accepted 20 May 20161Communicable DiseasePrevention and ControlServices, British ColumbiaCentre for Disease Control,Vancouver, British Columbia,Canada2School of Population andPublic Health, University ofBritish Columbia, Vancouver,British Columbia, CanadaCorrespondence toDr Jane A Buxton;Jane.Buxton@bccdc.caABSTRACTObjectives: This study sought to identify factors thatmay be associated with help-seeking by witnessesduring overdoses where naloxone is administered.Setting: Overdose events occurred in and were reportedfrom the five regional health authorities across BritishColumbia, Canada. Naloxone administration formscompleted following overdose events were submitted tothe British Columbia Take Home Naloxone programme.Participants: All 182 reported naloxoneadministration events, reported by adult men andwomen and occurring between 31 August 2012 and 31March 2015, were considered for inclusion in theanalysis. Of these, 18 were excluded: 10 events whichwere reported by the person who overdosed, and 8events for which completed forms did not indicatewhether or not emergency medical help was sought.Primary and secondary outcome measures:Seeking emergency medical help (calling 911), asreported by participants, was the sole outcomemeasure of this analysis.Results: Medical help was sought (emergencyservices—911 called) in 89 (54.3%) of 164 overdoseswhere naloxone was administered. The majority ofadministration events occurred in private residences(50.6%) and on the street (23.4%), where reportedrates of calling 911 were 27.5% and 81.1%,respectively. Overdoses occurring on the street(compared to private residence) were significantlyassociated with higher odds of calling 911 inmultivariate analysis (OR=10.68; 95% CI 2.83 to51.87; p<0.01), after adjusting for other variables.Conclusions: Overdoses occurring on the street wereassociated with higher odds of seeking emergencymedical help by responders. Further research is neededto determine if sex and stimulant use by the personwho overdosed are associated with seeking emergencymedical help. The results of this study will informinterventions within the British Columbia Take HomeNaloxone programme and other jurisdictions toencourage seeking emergency medical help.INTRODUCTIONThe British Columbia (BC) Take HomeNaloxone (THN) programme was implementedon 31 August 2012; it distributes naloxonekits to people who use opioids at sites acrossBC.1 Sites include public health units; phys-ician offices, methadone and communityhealth clinics; emergency departments anddetoxification services. The programme con-sists of two essential components: (1) over-dose prevention, recognition and responsetraining that participants are required tocomplete in order to be eligible to obtain akit, and (2) receiving a kit containing twoampoules of naloxone, an opioid antagonistwhich reverses the effects of an opioid-relatedoverdose, two retractable syringes and othersupplies (a full description is available athttp://www.towardtheheart.com/naloxone).2Kits are provided to opioid users only asnaloxone is a prescription only medicine inCanada.1 At the time this analysis was con-ducted, the programme had trained 3132 par-ticipants and distributed 2083 kits.3Consistent with other THN programmes, BCtraining emphasises seeking emergencyStrengths and limitations of this study▪ To the best of our knowledge, this is the firststudy to identify predictors of help-seekingduring overdoses within a state or provinciallevel naloxone distribution programme.▪ Also, to the best of our knowledge, this is thefirst quantitative study to identify predictors ofhelp-seeking following the administration ofnaloxone and to assess the possible independenteffects of factors related to naloxoneadministration.▪ Since events were reported voluntarily, studyparticipants may differ from individuals who didnot report naloxone administration events to theprogramme.▪ Responders to overdoses may have had limitedknowledge of some overdose characteristics,such as the substances used by the person whooverdosed.Ambrose G, et al. BMJ Open 2016;6:e011224. doi:10.1136/bmjopen-2016-011224 1Open Access Researchmedical help, by calling 911, as the first step in theresponse to an overdose.4Naloxone reverses the respiratory depressant action ofopioids within 2–5 min; however, its effect begins to wearoff 30 min after administration; thus, subsequent dosesof naloxone may be required for overdoses involvinglong-acting or high doses of opioids.2 5 Since 2012, BChas seen increasing rates of non-fatal and fatal overdosesinvolving illicit fentanyl, resulting in a province-widepublic health awareness campaign in March 2015.6–8Larger and repeat doses of naloxone may be required tosuccessfully reverse the effects of overdoses involvinghigh doses of fentanyl, compared to other opioids.9–11In addition, overdoses may involve multiple substancesor complex medical conditions further highlighting theimportance of lay responders calling for emergencymedical help.1 4 12 13Qualitative and quantitative studies have identifiedseveral factors which may discourage witnesses fromseeking emergency medical help when responding to anoverdose. Deterrents include lack of access to a phone,past negative experiences with first responders, and arespect for the ‘high’ of the person overdosing.14–17Fear of police attending and the belief that the personwould have or had recovered are frequently reportedreasons for not seeking emergency medical help insituations both where naloxone is, and is not, avail-able.1 12 16 18 19 Harassment by police or emergencyresponders has been reported in some evaluations ofnaloxone distribution programmes.13 20Quantitative studies have identified factors which areindependently associated with calling 911 by peopleresponding to overdoses. However, the relative import-ance of these predictors in overdoses where naloxone isadministered is unknown.21 22 To respond to this gap inthe literature, this study sought to identify factors asso-ciated with help-seeking by witnesses during overdoseevents where naloxone was administered.METHODSSampleNaloxone kits distributed by the BC THN programmeinclude an administration form that the kit owner isrequested to complete and return to the programme fol-lowing naloxone administration. Programme partici-pants are assisted in completing and returningadministration forms by site staff when they requestreplacement kits. Completion of the form is notrequired to obtain a new kit.Data collection and variablesInformation from the forms is entered into an ACCESSdatabase. Data regarding overdose events whichoccurred between 31 August 2012 and 31 March 2015were extracted during April 2015 and analysed todescribe rates and predictors of seeking emergencymedical help—defined as reported calling 911 duringan administration event. ‘Help-seeking’ denotes seekingemergency medical help by calling 911 in this article.Sex and age on administration forms corresponded tothe person completing the form. Age was categorisedinto quartiles.Substances used by the person who overdosed, asreported by the responder, were recoded into three vari-ables: (1) number of substances reported (1 or >1); (2)stimulants; and (3) non-opioid depressants. Since atleast one opioid was reported to have been involved inthe majority of events (95%), we also created a dummyvariable to assess the effect of using multiple opioids(≤one opioid or >one opioid).Geographic location of overdose was coded by the fiveBC regional health authorities; however, three healthauthorities (Northern Health, Island Health and FraserHealth) were collapsed into one category because therewere fewer overdoses reported in these authorities.Although Island Health, Fraser Health and VancouverHealth reported similar rates of calling 911, eventsoccurring in the latter were coded separately asVancouver is distinguished by its earlier adoption ofharm reduction policies and by a police policy of notattending apparent overdose calls.23–25 Similar to theapproach of Tobin et al,22 we categorised the overdosesetting on the basis of the level of privacy in a givensetting. Private residence and hotel were considered themost private and collapsed into one ‘private residence’category; ‘shelter’, ‘supportive housing’ and ‘other’ wereconsidered moderately private and coded as ‘other’;while ‘on the street’ was its own category and expectedto be the least private. The question related to with-drawal symptoms on administration forms included only‘none’, ‘mild’ and ‘severe’ options, which were retainedas categories in this analysis. Number of naloxone dosesadministered was collapsed into two categories becausethere was only one reported event where three ampouleswere administered. The programme’s duration as of 31March 2015 was divided into two equal periods of69.4 weeks and events were coded into either the first orsecond half of the programme.Data analysisDescriptive analysis identified the number and percen-tages of responses for factors which were thought to bepotentially associated with calling 911, based on theauthors’ reasoning, previous identification in the litera-ture and input from the BC THN community advisoryboard meetings involving programme stakeholders.Since we were interested in the effect of age and sex ofpeople who responded to overdoses (rather than the over-dose victim), we excluded forms completed by partici-pants who said that they had overdosed. UnadjustedORs were computed and variables with a p value ≤0.10were included in the multivariate model. Logistic regres-sion was used to assess the independent effects of poten-tial predictor variables with the odds of a respondercalling 911.2 Ambrose G, et al. BMJ Open 2016;6:e011224. doi:10.1136/bmjopen-2016-011224Open AccessSince some completed administration forms did notindicate if the person filling out the form hadresponded or had overdosed, we included a dummy vari-able in the multivariate model for role (responded vsnot indicated) to assess the possible confounding effectof not reporting role (regardless of its p value). Amongthose who did not indicate their role, it was unclear ifsex and age responses corresponded to the person whooverdosed or responded. On the basis of the smallnumber of individuals who said they overdosed (n=10),we assumed that the majority of the missing responsesfor role were people who responded. To test whetherreporting role modified the effect of sex, we conducteda sensitivity analysis which included an interaction termbetween sex and role.Some individuals reported administering naloxonemultiple times. To address the possible lack of indepen-dence between administration events reported by thesame individual, we allowed the logistic model’s disper-sion parameter to vary. In addition, we conducted a sen-sitivity analysis using a generalised estimating equation(GEE) on a subset of events for which an individualreporting them could be identified (n=65 individuals/clusters after observations with missing data excluded).Clusters were identified on the basis of the name of theperson completing the administration form, or bymatching age, sex and site information. We conductedadditional sensitivity analyses on subsets of observations(1) where the person admitted being the responder tothe overdose, using a logistic model (n=74 observationsafter cases with missing data excluded), and (2) onobservations where self-reported responders could beidentified by name or other identifiers, using a GEE(n=51 individuals/clusters after observations withmissing data were excluded).RESULTSAs of 31 March 2015, 182 administration events werereported to the programme. Of these, 18 events wereexcluded: 10 where the person who completed theadministration form indicated that they received thenaloxone, and 8 forms which did not indicate if 911 hadbeen called. Thus, our analysis was based on 164 events;however, the response rate varied for each explanatoryvariable. Multivariate analysis was conducted on 102forms where information was complete.Participant and overdose characteristicsOf 164 participants who indicated that they eitherresponded to the overdose (n=112) or did not indicatetheir role (n=52), 89 (54.3%) reported that 911 wascalled. Demographics for all 164 respondents are sum-marised in table 1; the mean age was 40 years and 58.3%of respondents were male.Table 2 lists characteristics of overdoses stratified bycalling 911. The Vancouver Coastal Health authorityaccounted for the most reported administration events(41.4%), while only one event was reported in NorthernHealth. The majority of events (50.6%) were reported tohave occurred in a private residence. In the first half ofthe period assessed, 46.3% of those who administerednaloxone called 911; in the second half, 60.6% did.Bivariate and multivariate associationsTable 3 presents unadjusted and adjusted ORs for allvariables. In the univariate analysis, the overdose occur-ring on the street, the responder being female, and theoverdose occurring during the second half of the THNprogramme were associated with higher unadjustedodds of calling 911 at p<0.10. Stimulant use by theperson who overdosed, reporting mild withdrawal symp-toms, and the overdose occurring in the Interior Healthregion were significantly associated with lower odds ofcalling 911 before adjusting for other variables.In the multivariate logistic model, the setting wherethe overdose occurred remained significantly associatedwith calling 911. The odds of calling 911 were higherwhen the overdose occurred on the street (AOR=10.68;95% CI 2.83 to 51.87) and in other settings (AOR=3.89;95% CI 1.03 to 16.47) compared to the overdose occur-ring in a private residence. Reported stimulant use bythe person who overdosed was significantly associatedwith lower odds of calling 911 (AOR=0.32; 95% CI 0.09to 0.98). Being female and the overdose occurring inthe Interior Health region were no longer significant.No significant associations were found between theoutcome and reported withdrawal symptoms, the periodof the THN programme during which the overdoseoccurred, and whether or not the person indicatedwhether they responded.Sensitivity analysesIn the logistic model which included an interactionterm between sex and role, the interaction term wasnon-significant (p=0.32) and all variables which wereTable 1 Demographic characteristics of clients whoindicated whether or not 911 was called (n=164)VariableNumber ofresponses* (%)*Sex, all participants (n=132)Male 77 58.33%Female 55 41.67%Sex, responders (n=93)Male 56 60.22%Female 37 39.78%Sex, role not indicated (n=39)Male 21 53.85%Female 18 46.15%Age, year (n=91)Mean, all participants (range) 39.78 (20–80)Mean, responders (range) 39.32 (21–80)Mean, role not indicated (range) 40.92 (20–60)*Except where otherwise indicated.Ambrose G, et al. BMJ Open 2016;6:e011224. doi:10.1136/bmjopen-2016-011224 3Open AccessTable 2 Calling 911 by reported demographic and overdose characteristicsVariableNumber of (%)responsesNumber of (%)called 911n=89Number of (%)did not call 911n=75Age (of person completing administration form) 91 (100.00) 50 (54.95) 41 (45.05)20–30 29 (31.87) 18 (62.07) 11 (37.93)31–41 16 (17.58) 8 (50.00) 8 (50.00)42–46 23 (25.27) 16 (69.57) 7 (30.43)47–80 23 (25.27) 8 (34.78) 15 (65.22)Sex (of person completing administration form) 132 (100.00) 72 (54.55) 60 (45.45)Male 77 (58.33) 36 (46.75) 41 (53.25)Female 55 (41.67) 36 (65.45) 19 (34.55)Health authority 162 (100.00) 88 (54.32) 74 (45.68)Vancouver Coastal Health 67 (41.36) 44 (65.67) 23 (34.33)Interior Health 44 (27.16) 10 (22.73) 34 (77.27)Fraser Health 39 (24.07) 27 (69.23) 12 (30.77)Island Health 11 (6.79) 7 (63.64) 4 (36.36)Northern Health 1 (0.62) 0 (0.00) 1 (100.00)Overdose setting 158 (100.00) 81 (51.27) 77 (48.73)Private residence 80 (50.63) 22 (27.50) 58 (72.50)On the street 37 (23.42) 30 (81.08) 7 (18.92)Hotel 14 (8.86) 8 (57.14) 6 (42.86)Other 11 (6.96) 7 (63.64) 4 (36.36)Shelter 8 (5.06) 8 (100.00) 0 (0.00)Supportive housing 8 (5.06) 6 (75.00) 2 (25.00)Programme period (weeks) 150 (100.00) 85 (56.67) 65 (43.33)<69.4 41 (27.33) 19 (46.34) 22 (53.66)≥69.4 109 (72.67) 66 (60.55) 43 (39.45)Number of ampoules administered 151 (100.00) 82 (54.30) 69 (45.70)1 86 (56.95) 44 (51.16) 42 (48.84)2 64 (42.38) 37 (57.81) 27 (42.19)3 1 (0.66) 1 (100.00) 0 (0.00)Withdrawal symptoms 139 (100.00) 73 (52.52) 66 (47.48)None 72 (51.80) 45 (62.50) 27 (37.50)Mild 47 (33.81) 18 (38.30) 29 (61.70)Severe 20 (14.39) 10 (50.00) 10 (50.00)Aggression 132 (100.00) 75 (56.82) 57 (43.18)No 105 (79.55) 63 (60.00) 42 (40.00)Yes 27 (20.45) 12 (44.44) 15 (55.56)Number of substances involved 158 (100.00) 86 (54.43) 72 (45.57)1 85 (53.80) 48 (56.47) 37 (43.53)2 50 (31.65) 31 (62.00) 19 (38.00)3 17 (10.76) 3 (17.65) 14 (82.35)≥4 6 (3.80) 4 (66.67) 2 (33.33)Substances involved* 158 (100) – –Heroin 142 (89.87) 78 (54.93) 64 (45.07)Fentanyl 35 (22.15) 18 (51.43) 17 (48.57)Morphine 11 (6.96) 5 (45.45) 6 (54.55)Methadone 9 (5.70) 2 (22.22) 7 (77.78)Codeine 4 (2.53) 0 (0.00) 4 (100.00)Oxycodone 4 (2.53) 4 (100.00) 0 (0.00)Hydromorphone 1 (0.63) 0 (0.00) 1 (100.00)Methamphetamine 16 (10.13) 7 (43.75) 9 (56.25)Cocaine 16 (10.13) 5 (31.25) 11 (68.75)Alcohol 16 (10.13) 9 (56.25) 7 (43.75)Benzodiazepine 6 (3.80) 4 (66.67) 2 (33.33)GHB (gamma-hydroxybutyrate) 1 (0.63) 1 (100.00) 0 (0.00)Other 2 (1.27) 0 (0.00) 2 (100.00)Role 164 (100.00) 89 (54.27) 75 (45.73)Responded 112 (68.29) 64 (57.14) 48 (42.86)Not indicated 52 (31.71) 25 (48.08) 27 (51.92)*Total numbers and percentages not shown for all columns as responses totalled more than 100% of participants.4 Ambrose G, et al. BMJ Open 2016;6:e011224. doi:10.1136/bmjopen-2016-011224Open Accesssignificant in table 3 remained so at the same level ofsignificance. In the GEE model based on 65 individuals,the overdose occurring on the street and in other areasrelative to a private residence remained highly signifi-cant (p<0.01). Being female was significantly associatedwith calling 911 in the GEE model (p=0.03), whilestimulant use was associated with the outcome at thesame level (p=0.07). The overdose occurring in InteriorHealth was not significant (p=0.21).In the logistic model based on the restricted sample ofpeople who indicated that they responded (n=74), theoverdose occurring on the street remained associatedwith increased odds of calling 911 (p=0.01), but theoccurrence of the overdose in the ‘other’ settingsTable 3 Unadjusted and adjusted odds of Calling 911 during overdoses where naloxone is administeredOverdose characteristics Unadjusted OR 95% p Value Adjusted OR* 95% CI p ValueAge20–30 Ref31–40 0.64 (0.18 to 2.31) 0.5041–46 1.48 (0.45 to 5.06) 0.5247–80 1.21 (0.38 to 4.01) 0.75SexMale Ref RefFemale 2.16 (1.06 to 4.49) 0.04 2.42 (0.88 to 7.05) 0.10Health authorityVancouver coastal health Ref RefInterior health 0.15 (0.06 to 0.36) <0.001 0.30 (0.06 to 1.20) 0.10Other† 1.05 (0.48 to 2.29) 0.91 0.86 (0.28 to 2.57) 0.8Overdose settingPrivate residence‡ Ref RefOn the street 7.26 (3.01 to 19.74) <0.0001 10.68 (2.83 to 51.87) <0.01Other§ 5.93 (2.28 to 17.61) <0.001 3.89 (1.03 to 16.47) 0.05Person who overdosed used more than one drugNo RefYes 0.75 (0.39 to 1.40) 0.37Person who overdosed used more than one opioidNo RefYes 0.75 (0.36 to 1.54) 0.43Person who overdosed used a stimulant¶No Ref RefYes 0.46 (0.20 to 1.02) 0.06 0.32 (0.09 to 0.98) 0.05Person who overdosed used a depressant (other than an opioid)**No RefYes 1.25 (0.50 3.24) 0.63Naloxone programme period (weeks)<69.4 Ref Ref≥69.4 1.90 (0.91 to 4.01) 0.09 1.56 (0.41 to 6.00) 0.51No. of ampoules administered<2 Ref≥2 1.28 (0.67 to 2.47) 0.46AggressionNo RefYes 0.53 (0.22 to 1.26) 0.15Withdrawal symptomsNone Ref RefMild 0.37 (0.17 to 0.79) 0.01 0.98 (0.31 to 3.12) 0.97Severe 0.60 (0.22 to 1.66) 0.32 0.81 (0.21 to 3.07) 0.75RoleResponded Ref RefNot indicated 0.69 (0.35 to 1.35) 0.28 1.81 (0.58 to 5.86) 0.31*Multivariate analysis conducted on n=102 complete cases.†Includes Northern Health, Fraser Health and Island Health.‡Includes responses of ‘private residence’ and ‘hotel’.§Includes shelter, supportive housing and responses of ‘other’.¶Includes methamphetamine, crack, cocaine.**Includes alcohol, benzodiazepines, GHB.Ambrose G, et al. BMJ Open 2016;6:e011224. doi:10.1136/bmjopen-2016-011224 5Open Accesscategory was not (p=0.05). Associations between sex andstimulant use had p values of p=0.10, p=0.09, respectively.The effects of geographic region, withdrawal symptomsand period of overdose were non-significant. In therestricted sample GEE model (n=51 individuals), theodds of calling 911 were significantly higher when theoverdose occurred on the street (p<0.01) or in other set-tings (p=0.02) and when the responder was female(p=0.01). No other significant associations, includingstimulant use (p=0.10), were identified.DISCUSSIONOur analysis found that emergency medical serviceswere sought in 54.3% of overdoses, which falls betweenrates of calling 911 reported in previous studies. In theiranalysis of current or past drug users in Baltimore,Tobin et al22 found that 911 was called in 45% of over-doses; 72% of events occurred in private residences. In astudy of people who use drugs in New York City, Tracyet al21 found that 911 was called in 67.7% of events;35.8% of events in this study occurred in private resi-dences. Consistent with our results, Tracy et al found thatthe setting in which the overdose occurs is significantlyassociated with calling 911 during an overdose. Theysuggested that the effect may relate to a greater level ofanonymity and lower risk of negative interactions withthe police.21 Similarly, in interviews with people who usedrugs who had received overdose response training,Lankenau et al14 found that calling 911 in a public spacewas easier because responders and witnesses could fleethe scene if necessary. They also reported one partici-pant’s concern that neighbours might see first respon-ders at this participant’s residence.14 It is also possiblethat people who use drugs keep illicit belongings athome or that unobserved characteristics of people whouse opioids, responders or overdoses differ in private set-tings compared to public ones.26 Further qualitativeresearch could elucidate other reasons why help-seekingdiffers in public versus private settings.Although not significant in our main model, theeffect of the sex of the responders remained significantin the generalised estimating equations. Tobin et al22found that the presence of female witnesses other thanthe responder was independently associated with higherodds of calling 911, but found no independent effectfor the responder’s sex. Other research shows that atti-tudes towards police and willingness to call the policeare influenced by past experience with police, includingthe perceived quality of treatment by police and the typeof police intervention.27–32 Tobin et al22 found that theeffect of fear of arrest on calling 911 may be modifiedby past exposure to police during witnessed overdoses.Women are accused of fewer and different crimes thanmen in Canada.33 It is possible that the frequency or thenature of interactions with police differs for femaleresponders and that women are consequently less averseto seeking help. As some social psychology researchsuggests, gender roles may also contribute to differencesin help-seeking behaviour.34 More research is needed tounderstand the role of sex on help-seeking duringoverdoses.Although not assessed in this study, some social vari-ables and the responder’s own overdose history couldalso influence help-seeking behaviour. Tobin et al22found that the presence of four or more bystandersduring an overdose and the responder having previouslyoverdosed were negatively associated with calling 911.Experience witnessing a fatal overdose was positivelyassociated with calling 911.22 Tracy et al21 found thatresponders who had ever overdosed were less likely toseek medical help compared to those who had neveroverdosed. Among those who had overdosed, havinggone to the hospital at their last overdose was positivelyassociated with seeking emergency medical help.21Future research within the programme could assess therole of these factors.To the best of our knowledge, this is the first quantita-tive study to assess predictors of responders’ help-seekingbehaviour in the context of a state or province-levelnaloxone distribution programme, and the only quantita-tive Canadian study to assess overdose help-seeking behav-iour. In addition, this was the first study to assess theeffects that factors related to naloxone administrationhave on the likelihood of seeking medical help, althoughnone of these were significant in the multivariate models.Recent research shows that the number of sites distribut-ing naloxone in the USA more than tripled between2010 and 2014.35 These results can inform the develop-ment of community-based naloxone programmes inNorth America and elsewhere.The findings of this study should be interpreted in thelight of several limitations. Data were self-reported andreported voluntarily. The programme is aware of consid-erable under-reporting, based on the number of replace-ment kits requested. We are aware anecdotally that someof the participants with multiple administrations do notreport each administration. It is not known if overdoseresponders who complete administration forms differfrom responders who do not complete the forms withregard to calling 911, the explanatory variables or both.Our sample included some observations where therespondent’s role was not indicated. We attempted toassess the impact of missing role data on our results bycontrolling for role in our full sample model, by testingthe role-sex interaction term and by comparing ourmain results with analyses conducted on a subset whosaid that they responded. Similar results between the fulland restricted sample logistic models, and between GEEmodels, suggest that the magnitude of possible bias frommissing role data is small; the direction of this possiblesource of bias is unknown. The quality of data providedon forms is also uncertain as forms may have been com-pleted hastily and information may have been subject torecall and social desirability bias. In addition, respondersto overdoses may have had limited knowledge of some6 Ambrose G, et al. BMJ Open 2016;6:e011224. doi:10.1136/bmjopen-2016-011224Open Accessoverdose characteristics, such as substances involved inoverdoses. The sample size was small and missingresponses mean that multivariate analysis was conductedwith only a subset of observations producing wide CIs.These limitations could impact the generalisability ofour findings. However, our study is the first to evaluatepredictors of help-seeking behaviour in the context ofprovince-wide naloxone distribution programme and isnot restricted to urban centres.Our findings have several implications for the BCTHNprogramme and harm reduction activities in BritishColumbia. Programme drug alerts and other communi-ques distributed to stakeholders will continue to stressthe importance of calling 911 during overdoses, espe-cially in a context of rising fentanyl-related deaths.Reluctance to call 911 from private residences under-scores the need to emphasise ways to call 911, whichminimise the likelihood of police attendance, such asindicating that a person is not breathing or unconsciousand avoiding explicit mention of overdose. Similarly,training can recommend that participants share thesestrategies with their friends and family members whomay be most likely to respond to an overdose or partici-pants can encourage loved ones to attend training. InVancouver, clients of harm reduction services can bemade aware of the Vancouver Police Department’spolicy of not routinely attending overdose calls (onlywhen death or violence has occurred or requested byemergency responders), which is the only policy of itskind in Canada.25 Qualitative research to understandwhy overdose setting and sex are associated with the like-lihood of calling 911 could inform additional measuresto promote help-seeking during overdoses. Lastly, at afederal level, authorities should consider legal reformsthat provide immunity from drug possession or drug usecharges for overdose responders, such as the ‘GoodSamaritan Laws’ enacted in many US states.36Acknowledgements The authors would like to thank the study participantsand to acknowledge the contribution of Dr. Robert Balshaw, Senior Scientistat the BC CDC, who provided guidance regarding the statistical analysis.Contributors GA contributed to the study design, performed the statisticalanalysis and drafted the manuscript. AA contributed to the study design anddata collection, interpreted the statistical analysis, and critically reviewed andrevised the manuscript. JAB contributed to the study design, interpreted thestatistical analysis, and critically reviewed and revised the manuscript. Allauthors have read and approved the final version.Funding This research received no specific funding from any funding agencyin the public, commercial or not-for-profit sectors.Competing interests None declared.Ethics approval UBC Behavioural Ethics Board approval and the approval ofappropriate local health research ethics boards.Provenance and peer review Not commissioned; externally peer reviewed.Data sharing statement No additional data are available.Open Access This is an Open Access article distributed in accordance withthe Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license,which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, providedthe original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/REFERENCES1. Oluwajenyo Banjo MPHc, Tzemis D, Al-Qutub D, et al. 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