Police officers’ perceptions of their role at overdose events: a qualitative study

Abstract

Introduction

The Good Samaritan Drug Overdose Act, a federal law enacted in Canada in 2017, aims to increase bystander response to overdoses by offering legal protection for arrests related to simple possession at the scene of an overdose. As this legislation suggests, a shift has occurred to view overdose events as a medical issue, constituting a shift in the role of police officers. Our study aimed to uncover the role police perceive for themselves at overdose events.

Methods

Twenty-two qualitative interviews were conducted with police officers across British Columbia (BC). A thematic analysis was completed to identify patterns in the data.

Findings

Police officers perceived their primary role was to ensure the safety of first responders and bystanders at overdose events. Some officers favored enforcing mandatory treatment and used coercive practices to ensure overdose victims received further medical care.

Discussion

Policies which reframe overdose events in terms of a health rather than criminal response put into question whether police officers have a role at overdose events and, if so, what it is.

Conclusions

Education and awareness are needed to reduce stigma towards people who use drugs, misunderstandings around naloxone and harmful practices such as coercion, at overdose events.

Keywords:

• Police officers
• first responders
• drug overdose response
• coercive treatment
• Good Samaritan Drug Overdose Act

Introduction

In recent years, overdose deaths have considerably increased in the United States and Canada—leading to the declaration of public health emergencies in various jurisdictions, such as British Columbia (Dyer, 2019; Xibiao et al., 2018). The COVID-19 pandemic has worsened this crisis. In British Columbia (BC), Canada, overdose deaths in 2020 and 2021 were the highest on record (BC Coroners Service, 2021). Naloxone, a medication that reverses an opioid overdose, can save lives when administered. However, even if naloxone is given by bystanders and the overdose is reversed, seeking emergency care by calling 9-1-1 is important (Canadian Centre on Substance Abuse & Canadian Community Epidemiology Network on Drug Use, 2017). Synthetic opioids (e.g. fentanyl, carfentanil) and other substances (e.g. benzodiazepines) increasingly found in street drugs (Office of the Provincial Health Officer, 2019) increase the risk of complications when an overdose occurs (Canadian Community Epidemiology Network on Drug Use, 2016) and overdoses can recur when the effects of naloxone wear off (Canadian Centre on Substance Abuse & Canadian Community Epidemiology Network on Drug Use, 2017). It is therefore important that medical care be sought even when naloxone is administered by bystanders.

When 9-1-1 is called in BC, dispatchers will determine whether to alert police, paramedics, fire services, or a combination of the three. This decision is guided by a ‘non-informing’ BC Emergency Health Services (BCEHS) policy that was implemented in 2016. A non-informing policy refers to the procedure aimed at not routinely informing police of overdose events (Mehta et al., 2021). The aim is to encourage people to call 9-1-1 in the event of an overdose and reduce concerns around police presence (Karamouzian et al., 2019). Evidence suggests that this policy and reducing police attendance at overdose events, more generally, is effective (Butler-McPhee et al., 2020; Koester et al., 2017; Latimore & Bergstein, 2017; Moustaqim-Barrette et al., 2019; Tracy et al., 2005). However, police officers do attend overdose events in some cases. For example, BC’s non-informing policy includes a caveat that police will be notified of overdose events when there are safety concerns (e.g. attempted suicide, risk of violence or death). Moreover, police officers may come across overdoses during their shift and be the first bystander and/or first responder that can respond. To minimize concerns in cases when police officers are present at overdoses, in 2017 the Government of Canada enacted the Good Samaritan Drug Overdose Act (GSDOA) (Government of Canada, 2021). The GSDOA provides legal protections around drug possession as well as charges for breach of probation, pre-trial release, conditional sentences, and parole relating to simple drug possession for people at the scene of an overdose.

A major concern related to police officers presence is police discretion (i.e. the power to choose how, when and to what extent they enforce laws), which is a driver of inconsistent approaches taken by police at overdose events (Koester et al., 2017; Rouhani et al., 2021; Selfridge et al., 2020; Xavier et al., 2021). The use of discretion by police is shaped by the attitudes of police officers towards substance use, police officers’ behaviors at overdose events, and the role that police officers believe they should play at these events (del Pozo et al., 2021). Police officers’ views and roles at overdose events may be influenced by the evolving sociolegal context surrounding substance use (Greer et al., 2022).

In recent years, the publicized problematization of the criminal justice system and over-representation of marginalized populations (e.g. people who use drugs (PWUD)) along with increasing overdose deaths, among other forces, has contributed to a growing discussion about the harms of approaches rooted in deterrence or abstinence (Angus Reid Institute, 2021; Global Commission on Drug Policy, 2016; Office of the Provincial Health Officer, 2019). More and more, substance use is being recognized as a health issue, rather than criminal one, that requires public health measures. Evidence of this includes: the enactment of the GSDOA, the legalization of cannabis, police officers carrying naloxone and support for decriminalization (Greer et al., 2022). In 2020, the Canadian Chiefs of Police released a public statement in support of decriminalization (Canadian Association of Chiefs of Police, 2019). Since then, Vancouver and British Columbia have applied for federal exemptions to decriminalize simple possession (City of Vancouver, 2021; Government of British Columbia, 2021).

While the sociolegal context is evolving, the direction in which changes are occurring may not represent the views of all police officers. Parallel to changes in perceptions of substance use and drug policy is a broader discussion about the fundamental role of police officers in society. The role of police officers is defined by an array of tasks, including using situationally justified force, enforcing laws, providing emergency medical care and providing social support (Bittner, 1974; Bullock, 2013; Chriss, 2011; Loadner, 2020). Discussion and critiques of the appropriate roles for police officers and potential contradictions between various roles have a well-established history (Bittner, 1974; Bullock, 2013; Chriss, 2011; Zakimi et al., 2022). Most recently, in 2020, protests surrounding police brutality towards racialized communities erupted in the US and parts of Canada (Maynard, 2020). In response, some advocated for police reform that would center the mission and training of police institutions around responding to crises and issues of social marginalization with de-escalation tactics (Collier, 2017; Mukherjee, 2020). Others advocated for abolishing the role of police (Illing, 2020; McDowell & Fernandez, 2018; Vitale, 2017). While these are fundamentally different proposed solutions, both assert evidence that maintaining order and security is not attained through police force and penalties but rather action to address inequities for groups that have been and continue to be socially marginalized (Hovermann & Messner, 2019). Rooted in this understanding of the ineffectiveness of deterrence-based approaches and criminal justice system involvement for low-level crimes, including illicit substance use, is a body of literature that explores a new framework for policing—harm reduction policing (Barry, 2018; Beckett, 2016; Kammersgaard, 2019). Harm reduction policing has been defined as policing that is informed by harm reduction principles with the objective of guiding police discretion and responses to low-level crimes to support individuals and communities and reduce harms associated with criminal justice involvement (Beckett, 2016). Growing interest in harm reduction policing and alternatives to deterrence-based approaches for low-level crimes are connected to the expansion of the role of police officers. In BC as well as other jurisdictions, police officers are increasingly being expected to wear many hats, acting as social workers, law enforcement, mental health practitioners, etc. (Zakimi et al., 2022). Police officers may not have appropriate training for some of these roles and, overall, these roles may contradict each other and contribute to nebulous expectations (Abdollahi, 2002; Biddle, 1979; Zakimi et al., 2022). Indeed, at overdose events, police officers may be expected to provide a medical response, minimize over-crowding, respond to safety concerns and connect the overdose victim with appropriate services and resources after they have received medical attention (Greer et al., 2018; Selfridge et al., 2020; Zakimi et al., 2022).

Institutional and societal shifts in relation to occupational roles are not specific to the institution of policing. Healthcare, for example, has also wrestled with definitions of ethical care and healthcare professionals’ role in the lives of people experiencing health issues (Fakhoury & Priebe, 2007; Leinster, 2002; Salmond & Echevarria, 2017). One example of this is the evolution and move away from coercive care, as evidenced, most notably, by the deinstitutionalization of people with mental illness (Fakhoury & Priebe, 2007). As (Chan, 2007) suggests there is a need to analyze these institutional shifts from the perspective of occupational agents responsible for enacting change. Sensemaking, as Chan (2007) defines it, refers to how agents translate social or institutional changes into shared understandings and values that consequently influence their practices and perceived role. Sensemaking is particularly relevant in the context of police officers’ role at overdose events as, with the advent of naloxone, non-informing policies, and decriminalization in overdose contexts, their role relative to people who use drugs is rapidly changing. Moreover, it is unclear how police officers’ views of their role has evolved and how discretionary police practices are changing to negotiate between new occupational guidelines and antithetical views.

While police have been consulted about their attitudes towards specific harm reduction measures including naloxone and overdose prevention sites (Green et al., 2013; Heavey et al., 2018; Rando et al., 2015; Ray et al., 2015), researchers such as Ziarnowski (2020) note that few studies have assessed police officers’ general experiences responding to overdoses. Findings indicate that police experience feelings of burnout and helplessness from responding to overdoses and not seeing an ‘end in sight’ to the overdose crisis (Saunders et al., 2019; Ziarnowski, 2020). A deeper examination of officers’ experiences and perceived role at overdoses is needed, including officers’ insights into their perceived roles and actions in a decriminalized context (i.e. under the GSDOA), as well as their concerns and recommendations around their future attendance at overdoses. Such research has the potential to directly inform policing, including policies relating to the extent to which police can use discretion (Xavier et al., 2021). This understanding is particularly important in BC, where the role of police officers under proposed decriminalization schemes is shifting. An accurate understanding of the role police officers perceive for themselves in the context of the overdose crisis in BC is necessary for anticipating drug policy implementation challenges and providing police officers with the necessary information, training and tools to support them as their role evolves (del Pozo et al., 2021).

In this study, we aim to explore police officers’ roles at the scene of an overdose as perceived by officers themselves. In Canada, we have the Royal Canadian Mounted Police, Canada’s National Police Service, provincial police in certain provinces (e.g. Quebec), and municipal police. The Royal Canadian Mounted Police in contrast to provincial and municipal police differ based on enforcement duties, organizational structure, training and where they are posted. For example, in the province of BC, the Royal Canadian Mounted Police are often present in more rural areas. We recruited both municipal police officers and Royal Canadian Mounted Police to diversify the sample and identify potential organizational differences in police perceptions and actions. We asked police officers in BC to describe their experiences witnessing and responding to overdoses, training with and administering naloxone, and the benefits and challenges associated with police attendance at the scene of an overdose.

Methods

This study draws on qualitative interview data collected from police officers across BC between January and May 2020. Police officers were recruited through municipal police and Royal Canadian Mounted Police departments. To support recruitment, we leveraged pre-existing professional relationships with police departments and officers through our Drug Overdose and Alert Partnership (Buxton et al., 2018). Initially, convenience sampling was employed, followed by purposeful sampling to promote diversity in jurisdictions and participant demographics (age, gender, policing experience) (Patton, 1999).

An email was sent to key contacts in police departments who shared information about the study with their co-workers. Interested police officers were encouraged to directly contact the research coordinators. Eligible and interested officers received a consent form with study information to review and sign, for those choosing to participate, prior to the interview. Participants did not receive honorarium and participation was voluntary. They were assured that confidentiality would be maintained by de-identifying transcripts (i.e. removing identifying information such as names, locations, etc.) and secure storage of the data through encryptions and password protection. Research coordinators conducted one-on-one interviews over the telephone due to COVID-19 and physical distancing guidelines. The literature identifies key benefits and challenges surrounding telephone interviews. Challenges include: higher refusal rates for participation (Fowler, 2013; Sarantakos, 2012) and difficulties establishing rapport (Gribble et al., 2000; Kraus & Augustin, 2001). In contrast, phone interviews can promote recruitment from geographically diverse regions (Brinkmann & Kvale, 2015) and increase anonymity and participant comfort and consequently willingness to share (Blumberg et al., 2003). While phone interviews may come with unique benefits and challenges, research suggests that the overall quality of thedata collected is not associated with the medium i.e. face-to-face or phone interview (Novick, 2008). A semi-structured interview guide, developed and iteratively revised by the research team, supported these interviews. Questions on the guide relating to the current study included: ‘Can you tell me about a time that you were called to an overdose?’ and ‘What do you see as your role at an overdose?’. As data collection progressed, the research team met periodically to discuss emerging topics and additional questions or probes to promote a richness and depth to the dataset. The interviews each lasted approximately one hour. The interviews were audio-recorded, transcribed by a professional transcription service and uploaded to a qualitative data management software, NVivo 12 (NVivo qualitative data analysis software; QSR International Pty Ltd. Version 12).

The data was analyzed utilizing a thematic approach similar to that outlined by Nowell et al. (2017), employing the following steps: (1) familiarization with the data through engaging with transcripts and interview notes, (2) generating initial codes through open-ended coding, group discussion and building a coding framework, (3) searching for themes by visualizing connections in the data and taking note of concepts and how they connect to one another, (4) reviewing themes by going back to the raw data and engaging in conversation with the research team and (5) defining and naming themes.

The framework development and coding process aimed to promote the trustworthiness of findings through collaboration and discussion (Morrow, 2005; Nowell et al., 2017). We began by independently reading and open coding a sample of five transcripts to develop initial high-level descriptive codes. We met to discuss initial impressions of patterns and connections in the data and developed a consensus-based preliminary coding framework after review of our independent open coding and group discussion of the similarities and disparities in our interpretations. We then applied the coding framework to two transcripts to identify any potential redundancies or gaps. Following this initial process, we met to refine the coding framework and ensure there was consensus with regards to the definition, depth, and breadth of codes and sub-codes. After consensus on the final coding framework, two researchers applied it to all transcripts in NVivo. These team members independently coded all remaining transcripts and met after every three transcripts to discuss interpretations of the data and potential challenges in the process.

To refine the themes and findings in the current study, the lead author further analyzed the data relating to police officers’ experiences at overdose. An inductive approach was employed to capture re-occurring and fragmented concepts and link them into themes and sub-themes. This entailed going back and forth between the raw data, codes, themes and sub-themes and theory and literature with an eye to the sociopolitical context in BC and the context of policing and harm reduction. The lead author used two major techniques. Firstly, detailed notes were taken for each code to capture concepts, findings, patterns and isolated narratives. These notes were discussed with the research team before going back to develop thematic categories, compare content, and make connections between ideas. This process elicited a first set of potential themes and sub-themes. Secondly, concept mapping and various visualization techniques were employed to consider and determine redundancies, overlap and gaps in the first set of themes and sub-themes, and to synthesize the data into more granular themes and sub-themes (Butler-Kisber & Poldma, 2010). Throughout this process, the analysis team regularly discussed concepts, narratives and relationships between ideas and themes, as well as our interpretations of the findings. We intentionally examined the presence and absence of ideas within the themes, as well as discrepancies between interpretations. The coding and thematic analysis process resulted in a rich understanding of codes, themes, and findings (Green & Thorogood, 2013). All authors discussed and contributed to synthesizing the data into the final discrete themes and sub-themes and selecting excerpts that exemplified them.

The study protocol was approved by the University of British Columbia’s research ethics board (H19-01842).

Findings

Twenty-two police officers across BC participated in the study. Officers were recruited from metropolitan (population >500,000), large urban (population >100,000) and medium urban (population 30,000-100,-000) centers. Participants’ ages ranged from 30 to 51 years old (median: 41 years) and length of time working as apolice officer ranged from 1.5 to 28 years (median: 12.25 years). Nineteen participants identified as men and three as women. A summary of participant characteristics is presented in Table 1.

Table 1. Characteristics of police officers participating in qualitative interviews.

Participant characteristics	Number of participants (N = 22)
Department^a
Metropolitan (population >500,000)	6 (27%)
Large Urban (population >100,000)	9 (41%)
Medium Urban (population 30,000–100,000)	7 (32%)
Police agency
Royal Canadian Mounted Police	9 (41%)
Municipal Police	13 (59%)
Age
30–39 years	9 (41%)
40–49 years	9 (41%)
50–59 years	4 (18%)
Gender
Man	19 (86%)
Woman	3 (14%)
Length of time as police officer
1–5 years	2 (9%)
6–10 years	8 (36%)
11–15 years	4 (18%)
16–20 years	6 (27%)
21 years or more	2 (9%)

^a The urbanicity of department locations were classified according to a system developed by the BC Ministry of Health which relies on definitions created by Statistics Canada while also taking into consideration remoteness, population density and proximity to urban areas (Statistics Canada, 2017; BC Ministry of Heath, 2019).

Below, we present the thematic findings on police officers’ perceived role at overdose events. Three themes related to this analytic category: (1) ensuring safety and perceived likelihood of violence at overdose events; (2) police officers’ perceptions of their medical role at overdose events; and (3) feelings of hopelessness in addressing the overdose crisis & enforcing treatment as a policing role.

Ensuring safety and perceived likelihood of violence at overdose events

In the interviews, police officers were asked about their experiences at overdose events and what they saw their role being. Police officers framed and prioritized their role at overdose events in terms of public safety: ‘Our primary role there is to keep the peace.’ (Participant 06). They emphasized the importance of providing safety for emergency health responders specifically: paramedics, fire services, other officers. Some participants explained that paramedics may request their presence as paramedics were not prepared to confront violence: ‘[Paramedics] don’t have either the training or the equipment to necessarily protect themselves and sometimes when people are unconscious and then get naloxone they become violent.’ (Participant 05). Prioritizing public safety was linked to concerns around violence or aggression from bystanders as well as the person overdosing. As two participants shared:

Ambulance likes to have some security there when they’re dealing with people. ‘Cause sometimes there’s groups of people and people get emotional ‘cause someone’s dying and it can be a pretty dramatic scene sometimes. (Participant 22)

When somebody comes out of an overdose, they tend to be quite combative or hostile. So, if they’ve got a needle in their hand or a weapon nearby sometimes they grab it as either a self-defence or sometimes they will attack the other first responders. So, we’re there to provide that safety barrier for them. (Participant 06)

The idea that syringes could be used as a weapon by persons overdosing was common: ‘They might still have syringes and there are concerns about obviously what the behaviours are going to be.’ (Participant 20). In some cases, officers referenced restraining or arresting persons, including the person overdosing and bystanders, whose behavior escalated: ‘She had to be restrained until she calmed down and ultimately ended up going to the hospital.’ (Participant 05). Officers viewed restraining individuals as normal and necessary for assisting emergency health providers: ‘We just basically made sure that he couldn’t fight with the ambulance and was calm enough to be able to put him in a stretcher.’ (Participant 15).

In addition to officers’ concerns of incidents of violence, some officers viewed the environments in which overdoses occurred as categorically unsafe. Officers explained that areas or neighborhoods that were perceived as unsafe by paramedics was a common reason to request police attendance. One officer stated: ‘If it’s in and around the shelters, sometimes—nighttime, they [paramedics] just may not feel safe going in initially.’ (Participant 20) and another said: ‘For the safety of the medical first responders. Because usually they’re going to sketchy places, you know, alleys.’ (Participant 05).

As a result of the perceived probability of violence at overdoses and perceived danger of locations where overdoses typically occur, many officers justified the need for police to attend overdoses for the safety of paramedics or other responders. Others believed this could be determined on a case-by-case or situational basis.

Police officers’ perceptions of their medical role at overdose events

Police officers’ role in the absence or delay of medical professionals

Many police officers perceived and framed overdose events as health matters, not criminal justice matters. For example, many participants felt it was unnecessary to attend all overdoses, emphasizing that they were not medical professionals. As one officer stated: ‘There’s not really much we can do, and we’re not really trained. We’re not medical personnel, right, so we have very limited abilities when it comes to overdoses.’ (Participant 02). While some officers did not see their role in terms of providing a medical response, they recognized that police officers felt compelled when there were delays among paramedics and firefighter attendance, often due to high call volumes, jurisdictional travel distances, and inadequate resources. As one officer said:

It’s important that a first responder gets to an overdose as soon as possible… paramedic resources are stretched very thin and they may not be able to be the first, you know, asset there. Same thing with the fire department… it’s better for the police to be there than nobody. (Participant 16).

The need to respond was especially evident among frontline patrol officers who came across persons overdosing in public settings:

The majority of the overdoses—it’s usually me coming across them. So I’ll be walking in a laneway or alley in the Downtown Eastside and I’ll find somebody not breathing. (Participant 01)

If I wouldn’t have found some of these people in alleys they’d be– numerous people dead. If we weren’t patrolling around where we were, there’d be nobody finding these people. ‘Cause if you don’t know where they go, their little nooks and crannies, you’d never find them. (Participant 18).

Frontline patrol officers emphasized the commonality of finding someone overdosing in a public setting and felt relieved that they could help. Officers viewed themselves as uniquely positioned in public spaces to monitor for overdoses, particularly in communities that are known for public drug use.

Police officers’ role in administering naloxone

The majority of police officers routinely carried naloxone on shift. Many described it as a beneficial tool that was provided to them by their department:

I’m just glad that we have the tools to be able to do this ‘cause in the beginning we didn’t have much naloxone and we’d have to rely on some of the ambulance people. (Participant 18).

Nasal naloxone was perceived as easy-to-use or, as several described: ‘fairly idiot-proof’. Police officers appreciated having access to nasal naloxone versus intra-muscular naloxone as the latter prompted concerns around injecting someone. As two officers shared: ‘I guess I could fumble through it, but I really don’t know how to use the I.M. [intramuscular] naloxone and the nasal that we always have and readily accessible is super easy to use. And I would definitely much prefer using that.’ (Participant 20) and: ‘For us, there’s always liabilities and risk. So the nasal spray is pretty failsafe.’ (Participant 04). Officers were both worried about the practical use of intramuscular naloxone as well as liabilities around it.

Many officers described carrying naloxone primarily for responding to on-the-job fentanyl exposure amongst themselves and their colleagues: ‘One of the police officers came into contact with what we later believed to be fentanyl in powder form during the search of this apartment and lost consciousness. And I administered Naloxone to her.’ (Participant 05). Officers believed touching or inhaling small amounts of fentanyl in their work could result in an overdose, revealing several misconceptions around the mechanisms of fentanyl poisoning: ‘vapour in the air when I touch them or grab them or search their pockets’ (Participant 04). One officer shared:

It’s happened a couple of times where an officer’s been handling fentanyl and began to feel the effects of it. Just through absorbing, whether it’s through their nose or skin or something like that. So it’s [naloxone] more for ourselves than someone else. (Participant 03)

Over one-third of participants reported they had never administered naloxone to reverse an overdose and among those who had, many had only administered naloxone 1–2 times in their career: ‘There was a couple times where the person was– I thought they were in real trouble and I used my personal issued naloxone on them. But generally it would be just try to get them into the recovery position, get their airway open. And wait for people who are better trained in providing healthcare.’ (Participant 03). Officers shared that it was infrequently required, and several appeared to hesitate to provide a medical response: ‘If someone’s in the process of an overdose, you’re just going to check to make sure, is there someone there that’s able to provide that support.’(Participant 08)

While police often arrived at an overdose scene before ambulance and fire services, many described not needing to provide medical assistance as community members were already responding with naloxone. Harm reduction organizations and people who use drugs seemed to provide essential services and supports for the community. For instance, police officers were able to get assistance from a nearby overdose prevention site:

For the vast majority of street overdoses, it’s the community themselves, the group of users that is actually there, that usually have already administered the naloxone to the person by the time we get there. (Participant 08)

I’ll tell one of the people that’s present to, like, okay, run to one of the overdose prevention sites and get somebody out here with a Narcan kit. And they usually come out with a Narcan kit. They’ll come out with even oxygen and oxygen masks. (Participant 01)

Some officers expressed confidence in community member response to overdoses, including administering naloxone. These supports relieved officers of the expectation to take on a health response role—one that many were uncomfortable in.

Beyond overdose response: Police officers perceived role in preventing and reducing overdoses

A sense of powerlessness and hopelessness in reducing overdose events

Participants reflected on their role in responding to substance use harms and feeling powerless regarding BC’s overdose crisis. They felt that they were not contributing to addressing the underlying issues driving the rate of overdoses resulting in the same people overdosing again and again. This led some police officers to question the need for police attendance at overdose events:

We’re just spinning our wheels. There’s—from a police officer standpoint it’s disheartening ‘cause it always feels like you’re not making—having any effect whatsoever on dealing with the problem. (Participant 19)

It doesn’t make sense for me for police to attend something like that that we have no expertise in or ability to help all that much. We get there and it’s a feeling of powerlessness. You’re, like, I need an ambulance here, and I’ll just wait. (Participant 21)

Some police officers felt they did not have the necessary tools or recourses to offer support to people at risk of an overdose: ‘There’s not really much we can do and we’re not really trained.’ (Participant 02) and ‘We’ll make that active offer about trying to get them in touch with resources in the community. But it’s very seldom taken advantage of.’ (Participant 20). Police alluded to a lack of clarity around their role at an overdose, especially in light of their training and expertise that lies outside of healthcare and the societal shift towards approaching overdoses as health issues.

Perceived solutions and roles for reducing overdose events

Considering the frustrations and feelings of hopelessness that officers expressed in relation to their role in the current response to overdoses in BC, we asked participants for potential recommendations or solutions. Answers varied but were mainly focused on bolstering health and social supports for people who use drugs.

Most officers were in favor of promoting abstinence-based and deterrence approaches to substance use. Opinions towards harm reduction were more diverse with several officers expressing resistance. For some, harm reduction was framed as: ‘Enabling… so over the top brutal that it’s just ridiculous.’ (Participant 19). Some officers advocated for more and longer sentencing for drug-related offences or encouraged better access to treatment for substance use:

A lot of people change their ways when they have a decent sentence. […] They come out looking wonderful and that’s their opportunity if they want to do the change, right. That’s their rehab. […] cause—is it more compassionate in my mind to deal with people and help them to jail or rehab or just watch them shoot up on the street all day. And I know if my daughter was doing it I know where I’d like her to be. (Participant 18).

When asked about potential solutions to the overdose crisis some officers suggested involuntary treatment or the ability to coerce or force mandated treatment as a favored approach, stating ‘It would be beneficial to have the courts have power to say this is mandatory treatment’ (Participant 13) or the opinion that ‘People should be enforced to go to rehab.’ (Participant 18). Some officers took it upon themselves to operationalize coercion in their practice by ensuring people who had overdosed went to the hospital afterwards:

I made him go. So he didn’t want to go but I told him, honestly, I was going to arrest you for some reason that I could just to get him there. (Participant 18)

This guy’s overdosed like five times today…I might insist that that person go to the hospital under The Mental Health Act or something, just saying, like, okay, we’ve got to break the cycle here. (Participant 01)

Officers removed autonomy from people overdosing, forcing them to go to the hospital or an enforced alternative. Some officers interpreted that the Mental Health Act, an Act in BC that permits involuntary admission to treatment for people with mental health issues (Government of BC, 2021), could be used, based on police discretion, to enforce admission to hospital.

Views that people should be mandated into treatment were coupled with the notion that people with substance use issues cannot make ‘good’ decisions for themselves and a fatalistic view of addiction and the overdose crisis: ‘They’re a slave to the drug itself, and they literally can’t stop.’ (Participant 01) and ‘There’s nothing really that you could change that’s going to change people using or prevent those overdoses from happening.’ (Participant 02).

Discussion

In this study, we examined police officers’ perceived roles at overdose events. Primarily, officers framed their role in terms of protecting the safety of other first responders and the public. Such perceptions were linked to concerns of violence from the person being revived from an overdose. In contexts where paramedics and fire services were delayed, police officers perceived their role as first responders as a necessity. Officers were supportive of carrying naloxone but did so primarily for themselves and colleagues, out of fear of fentanyl exposures. Aside from the role of first responder and to ensure safety, many officers questioned the need and usefulness of police attending overdoses. In the context of the overdose crisis, officers considered the ability to coerce people into treatment, as well as used coercive tactics to ensure people receive medical care after an overdose.

The most prominent role of police officers at overdose events was framed around ensuring safety for other first responders and the public, mainly out of concerns around potential violence at overdose events. A prominent role police officers have had throughout time is the role of protection through administration of justifiable force (e.g. restraining) (Bittner, 1970). This, in combination with the BCEHS non-informing policy in BC, that informs police officers of overdose events only when there are safety concerns, likely contributed to the importance police officers placed on their role at overdose events for promoting public and paramedic safety. However, broad and/or unspecific definitions of safety threats that warrant police attendance (e.g. the presence of a syringe) could be counter-productive to the aim of non-informing policies. Non-informing policies with caveats that permit informing police in the event of safety risks may benefit from specifying what does and does not constitute a threat to safety at an overdose. Safety concerns related to violence from people who use drugs and bystanders was especially emphasized among officers in this study in their descriptions of their public safety role. (Williams-Yuen et al., 2020) suggests that paramedics may also be concerned about aggression from people who use drugs at overdose events. As a result, the public safety role police officers emphasized may be, in part, due to paramedics concerns and requests for police security.

It is unclear if the magnitude of these concerns, among police officers and paramedics, is aligned with the frequency at which violent or aggressive reactions occur at overdose events. The evidence related to this is mixed, with some studies demonstrating that aggression and agitation are infrequently observed in patients in hospital emergency departments receiving naloxone for overdose (Sabzghabaee et al., 2014; Wong et al., 2019) and community settings (Moustaqim-Barrette et al., 2021) and others indicating that aggression is relatively common among PWUD receiving naloxone in community settings (Avetian et al., 2018; Belz et al., 2006; Parkin et al., 2020). To note, the setting of the overdose and overdose reversal may have an impact. Additionally, police officers often do not know what substance the person overdosing used. This may constitute a limitation as it is unclear whether perceived aggression is associated with opioid use, stimulant use or both. In the case of opioid use, aggression appears to be closely linked to administering an excessively high dose of naloxone resulting in acute withdrawal symptoms (Adapt Pharma Inc., 2017; Purssell et al., 2021)—pointing to an opportunity to educate first responders and bystanders about the risks and consequences of uninterrupted high naloxone dosages instead of a more phased approach based on signs and symptoms. In response to concerns around syringes potentially being used as weapons, there is no evidence of people who use drugs weaponizing syringes.

Given the criminalization of drug use and history of contentious relations between police and people who use drugs (Csete & Cohen, 2003; Small et al., 2006; Ti et al., 2013), it may be that the risk of violence and other safety concerns are inflated by the sheer presence of police in a health emergency. More research is needed to determine if pre-conceived biases are leading to inflated perceptions of violence at overdose events or if, indeed, police officers witness and experience considerable violence from people present at an overdose. Depending on the outcome, anti-stigma campaigns for police officers and paramedics, focusing on biases and stereotypes around people who use drugs could be valuable. However, caution should be exercised in implementing these types of training as studies suggest that evidence-based training can contribute to negative attitudes towards people who use drugs among police officers (Winograd et al., 2020). Alternatively, it may be necessary to examine the roots of aggression at overdose events and consider ways to provide medical attention while de-escalating the situation. As Parkin et al. (2020) suggest, effective communication skills and empathetic approaches from people responding to overdose events, including first responders, can mitigate aggression experienced at overdose events. Importantly, trauma-informed and de-escalation training is fundamental for police officers and paramedics interacting with survivors at the scene of a traumatic event (i.e. overdose).

In light of the non-informing policy in BC, our findings identify potential barriers to implementing such policies, including resource and geographic limitations. At times, police may attend an overdose quicker than paramedics and fire services. As officers noted, they may be required to respond to overdoses first due to delays in paramedics travelling to remote or rural areas. Region-specific research into non-informing policies and police versus paramedic attendance may further our understanding of the reasons why police continue to attend overdose events.

Police officers discussed their role at overdose events as medical emergency responders, when paramedics are delayed, or they are first on scene. Some police officers demonstrated discomfort with stepping into this role. Zakimi et al. (2022) found that increasingly police officers may be asked to offer a medical and/or mental health response, despite minimal training in these areas. Greater clarity and direction surrounding police officers’ role at overdose events is needed, especially given the evolving sociolegal context (e.g. GSDOA, dejure decriminalization). Narrowing the scope of police officers’ roles at overdose events and identifying systemic gaps police officers are asked to fill (e.g. medical first response) may contribute to better aligning training with police officers’ occupational tasks and increasing police officers’ comfort with various roles (Zakimi et al., 2022).

Within the sub-theme of police officers’ role as first responders, police discussed their experiences with naloxone, showing support for carrying it. This finding echoes the existing research showing that police officers view naloxone as a useful tool (Purviance et al., 2017; Ray et al., 2015; Smyser & Lubin, 2018; Wagner et al., 2016; Ziarnowski, 2020). Of concern, many police officers in our study described naloxone as a tool that is primarily intended for reversing fentanyl exposures for themselves and their colleagues—rather than overdoses among people who use drugs. Such beliefs were linked to misconceptions around fentanyl absorption and poisonings. However, to date there is only one verifiable incident of opioid exposure among first responders recorded in the literature (Bains, 2016a, 2016b) and this report has been questioned in terms of its validity (Herman et al., 2020). As Herman et al. (2020) state, the scientific research has yet to confirm first responder occupational exposure to opioids—only lay media reports have presented accounts of exposure, causing concern surrounding the scientific validity of these reports. Further adding to concerns around these reports of fentanyl exposures among first responders are the inclusion of nonspecific symptoms, such as dizziness, anxiety, and nausea. These symptoms do not match those of an opioid overdose and may instead be from a person’s own condition or anxiety surrounding exposure to fentanyl (Beletsky et al., 2020; Moss et al., 2017).

Perceived likelihood of fentanyl poisoning among law enforcement has been explored in other studies (Attaway et al., 2021; Persaud & Jennings, 2020; Winograd et al., 2020). These studies suggest that most police incorrectly believed that fentanyl poisoning can occur through skin contact (Attaway et al., 2021; Persaud & Jennings, 2020; Winograd et al., 2020). As Winograd et al. (2020), Beletsky et al. (2020) and Herman et al. (2020) point out, mainstream media likely contributed to these misperceptions. Numerous trained medical professionals have since aimed to rectify such beliefs by providing evidence of the extremely low risk of fentanyl poisoning through skin contact or inhaling trace amounts (Faust, 2018; Faust & Boyer, 2018; Moss et al., 2017). Our findings suggest that more training and education is needed to promptly address misconceptions of fentanyl poisoning across BC police departments. In the context of Chan (2007) conceptualization of sensemaking, (Weick et al., 2005) states ‘members of organizations often ‘talk a situation into existence’’. A deeper analysis of police officers’ attitudes towards their role as medical first responders is needed to elucidate opportunities, apprehensions and narratives that may be underlying perceptions surrounding fentanyl.

Finally, the perceived role of police officers at overdose events was framed in the context of BC’s overarching approach to addressing substance use issues. Most officers in this study favored treatment and deterrence or law enforcement approaches. Some police officers supported involuntary treatment and reported using coercive tactics to ensure people received medical care after an overdose. For some officers, this was perceived as their last recourse to addressing the overdose crisis as they expressed frustration at the contradictions and inefficiencies police officers’ associated with their roles at overdose events, wherein they are expected to take a rather passive role unless safety issues arise or are expected to provide a medical response, despite not being trained as medical first responders. This concept of frustration and tension surrounding ones’ occupational role has been coined as role conflict (Biddle, 1979) or role strain (Goode, 1960). Evidence shows that involuntary treatment negatively effects people who use drugs’ trust in healthcare systems and their likelihood of seeking out emergency or long-term care (BC Centre for Disease Control, 2021; Hall et al., 2014; Werb et al., 2016; Wittouck et al., 2013; World Health Organization, 2012). While the evidence is mixed, many studies show that involuntary treatment may result in poorer treatment outcomes compared to voluntary treatment (Klag et al., 2005; Oviedo-Joekes et al., 2014; Simpson et al., 1997). Moreover, an emphasis on involuntary treatment may be rooted in ideals surrounding abstinence and what is right and wrong. del Pozo et al. (2021) study assessed factors that influence police discretion and found that 56% of police ranked their personal sense of right and wrong as the most influential factor on the discretionary approaches they chose to employ. Personal beliefs surrounding abstinence may be mis-leading as abstinence and/or accessing abstinence-based treatment may be unrealistic or poorly aligned with lives and desires of some people who use drugs. Education around the negative repercussions of involuntary treatment should be prioritized, particularly in reference to groups that have historically had their human rights violated while forcibly being institutionalized (e.g. people with mental illness and substance use issues, Indigenous peoples, etc.) (Lamb & Weinberger, 1998; Lebenbaum et al., 2018; Mudde, 2018; Rand, 2011; Udwadia & Illes, 2020; Wyder et al., 2013). Importantly, as our findings suggest, gaps in knowledge surrounding an effective public health approach to overdoses as well as confusion surrounding police officers’ dynamic roles can lead to problematic occupational practices, such as coercive treatment.

Our findings suggest that, under the GSDOA's scope of decriminalization, police officers may be uncertain about their role. As a result, they may rely on their discretion and attitudes about substance use and effective responses to guide their actions. These findings are relevant beyond the GSDOA, as Vancouver and BC await responses to their application for an exemption to decriminalize simple drug possession. The roles police officers perceive for themselves and resulting occupational practices may be particularly important in the context of decriminalization as police officers’ roles will formally change—prompting individual officers to contend with their new role and how they see themselves using discretion to uphold the law. This has important implications for the implementation and effectiveness of drug policy reform.

Limitations

While this study offers unique insights into the role police officers perceive for themselves at overdose events, it does have some limitations. First, participants may have aligned their narratives with what is perceived as socially acceptable or desirable (Bergen & Labonté, 2020), and may inherently view and present the role of police in the community through a positive lens. As such, our data may be biased towards more favorable experiences and perspectives. To address this, we aimed to highlight diverse perspectives, including positive and negative experiences and perspectives. Gathering the views from others, including people who use drugs, bystanders, and other first responders, in an important area of future research. As well, most participants were from larger urban and metropolitan cities and, as such, the role of police and response to overdose in rural areas may vary considerably from that presented here. This qualitative study only begins to unpack the roles of police officers within one context, BC, and the extent to which the views in this paper are shared among other police officers in BC and elsewhere is unknown. Further research is needed in BC and across Canada to examine police officers’ perceived roles in addressing the overdose crisis and role strain police officers may be experiencing. Finally, we recognize that the context of the overdose crisis, policing, and drug policy in BC is unique relative to other jurisdictions in Canada and internationally. As such, the transferability of our findings to other contexts may be limited.

Conclusion

In conclusion, this study provides new and important insights into the perceived role of officers at overdose events. Amid the ongoing overdose crisis and criminalization of drugs in Canada, the role of police officers at overdose events will continue to evolve. Understanding how officers view their roles as law enforcement officers within a public health crisis and at health emergency events can help develop more effective and supportive policing roles moving forward and guide implementation of alternatives to policing where appropriate. Moreover, understanding the role police officers perceive for themselves at overdose events and amidst the overdose crisis may allow us to anticipate drug policy implementation successes and challenges and support police officers (e.g. training, education, tools) as their role evolves.

Acknowledgements

We would like to thank participating police officers and police departments as well as Laurel White for her role in data collection. The authors respectfully acknowledge that they live and work on the unceded traditional territory of the Coast Salish Peoples, including the traditional territories of xʷməθkwəy̓əm (Musqueam), Sḵwxw̱u7mesh (Squamish), and Səli̓əlwətaɬ (Tsleil-Waututh) Nations.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Additional information

Funding

This work was supported by the BC Ministry of Health. The funders had no role in the study analysis or preparation of the manuscript. The corresponding author had full access to all the data in the study and had final responsibility for the decision to submit for publication.