Model Overview
The overview model presented in Fig. 1 contains four model subsections corresponding to key feedback loops identified during the GMB sessions. The loops shown in red represent input from healthcare providers & harm reduction experts in GMB session 1. The loops shown in green represent input from law enforcement & first responders in GMB session 2. The loops shown in blue represent input from harm reduction experts & individuals who have experienced or witnessed an overdose in GMB session 3. The loops shown in pink emerged from panels of combined participants convened for GMB sessions 4 and 5.
Selected feedback loops from GMB session 1 explain the process by which individuals who experience an overdose and call 911 may subsequently interact with the healthcare system, resulting in linkages to treatment (R1, R2). Other loops from this session focus on cycles of burnout and traumatization among first responders who respond to overdoses (B1) and community perceptions of naloxone use emboldening people to use drugs as a barrier to naloxone acceptability (B2). Selected loops from GMB session 2 highlight feedback processes centered on bystander naloxone use and accessibility of naloxone in the community (R3, B3, R4, R5). Some of these loops explain alternative linkages to care, such as through community-based harm reduction teams (B3); and some describe the impacts of education about GSLs on naloxone use and the processes of data utilization by public health departments and other organizations as drivers of education initiatives and changing community perceptions of the epidemic (R4, R5). Selected feedback loops from GMB session 3 focus on community interactions with and trust in law enforcement and how fear of arrest and other repercussions may discourage individuals from calling 911 in the event of an overdose (B4, B5, R6). These loops also highlight the important role of relationship building between police and community-based groups to encourage a culture of harm reduction and enhance community belief in GSLs and trust in police. Four additional loops added after review of notes and discussions from GMB sessions 4 and 5 provide greater context and interconnectedness of previously discussed system feedback structures. These additional loops describe feedback processes related to naloxone acceptance and use (R7, B7), interactions between police and community-based harm reduction teams (B6), and effects of education on police willingness to abide by GSLs (R8). Several of these loops and their interactions are described in greater detail in the following discussion on model narratives.
Model Narratives
Narrative 1 - Overdose, Calling 911, and First Responder Burnout (Fig. 2)
Our first model narrative explains some of the mechanisms associated with interactions between people experiencing an overdose and first responders and is illustrated by two competing feedback loops, the reinforcing loop R1 (Fig. 2a) and the balancing loop B1 (Fig. 2b). R1 shows how calling 911 after an overdose can save lives which, in turn, sustains a higher population with OUD in the absence of linkages to treatment or other interventions aimed at reducing overdoses. As illustrated by R1, as there are more overdoses, an increased number of 911 calls are made to request that first responders attend to individuals experiencing an overdose; this leads to more lives saved and a reduction in deaths. Given that there is now a larger population of individuals living with OUD (independent of linkages of patients to treatment such as medication for opioid use disorder (MOUD)), there is now the potential for more overdoses and, thus, even more calls to 911 for assistance, perpetuating the “reinforcing” feedback cycle of overdoses in the community.
The competing balancing feedback loop B1 illustrates the impacts of first responder burnout on overdoses and overdose deaths, whereby treatment of patients that perpetuates stigma may lead to downstream effects of increased overdose deaths and decreased populations of people living with OUD in the community due to hesitation of bystanders to call 911. Loop B1 illustrates how an increase in overdoses in the community contributes to the traumatization and burnout of first responders attending to numerous overdoses, particularly repeated overdoses at the same address or with the same individuals(s). Burnout of first responders may subsequently lead to mistreatment of individuals experiencing an overdose, contributing to increased stigma and negative attitudes towards people who use drugs. This stigmatized treatment may, in turn, discourage patients and bystanders from calling 911 for fear of mistreatment by first responders. Ultimately, this could lead to fewer lives saved by first responder action and an increase in deaths from overdose in the community. The unfortunate “balancing” effect of this cycle comes from the reality that, as more overdose deaths occur, there are fewer individuals with OUD alive, which reduces the number of overdoses to which first responders are summoned.
Narrative 2 - Naloxone Use, Acceptability, and Linking Patients to Services (Fig. 3)
The second model narrative is characterized by another set of competing feedback loops, reinforcing feedback loop R3 (Fig. 3a) and balancing feedback loop B3 (Fig. 3b). This narrative shows the interacting factors associated with the acceptance and use of naloxone by bystanders and the linkage of people who use drugs to treatment and social services. The narrative captured by the reinforcing feedback loop R3 shows how increased naloxone use, in the complete absence of linkages to treatment, may have unintended downstream effects increasing the number of overdoses, necessitating further use of naloxone. When overdoses rise in a community, syndromic surveillance systems such as OD maps capture the rise in overdoses, leading to further public health efforts to predict overdose trends. These heightened surveillance activities and resulting public health communications to the community can produce a subsequent increase in the acceptability of naloxone due to public awareness of the rising opioid problem in their community. As public acceptability of naloxone increases, bystander naloxone use subsequently rises, leading to fewer individuals who experience overdose going to the hospital. If fewer overdose victims interact with the healthcare system following successful bystander administration of naloxone and are not linked to treatment, this may perpetuate rising overdoses in the community and demand for bystander naloxone use.
The balancing feedback loop B3 provides a direct counteraction to the reinforcing feedback cycle described in R3. In this loop, individuals refusing to go to the hospital following the successful administration of naloxone may be linked to services through community-based harm reduction services instead of through a hospital-based healthcare system. Like the process in R3, when overdoses rise in a given community, public health officials can predict overdose trends with more accuracy and alert the community by tapping into syndromic surveillance and other data sources for early detection of overdose spikes. Public health attention to the problem leads to greater acceptance and use of naloxone by the community. In contrast to R3, however, B3 depicts a process in which overdoses in the community stabilize as a result of overdose victims being linked to treatment and other services through the presence of community-based harm reduction teams.
Narrative 3 - Drug Arrests, Belief in Good Samaritan Laws, and Community Trust in Police (Fig. 4)
The third model narrative, described by a set of three interacting feedback loops—balancing feedback loops B4 and B5 (Figs. 4a & 4c) and reinforcing feedback loop R6 (Fig. 4b)—illustrates how communities interact with and perceive police and how these interactions and perceptions affect utilization of 911 during an overdose. The balancing feedback process B4 describes the situation in which interactions of individuals who use drugs with police promote avoidance of seeking help through 911 for fear of arrest and other repercussions from law enforcement. When individuals who witness an overdose call 911, there is a chance that police may show up at the scene of the overdose. There is, consequently, an increased likelihood that a drug arrest may occur, as opposed to scenarios where only EMS or firefighters arrive at the scene. Fear of arrest and other repercussions such as loss of housing or custody of children when police arrive at the scene may lead bystanders and past overdose victims to avoid calling 911 in the event of future overdoses, which can have other downstream system effects (e.g., increased risk of dying, decreased linkages to treatment and other services, etc.).
R6 describes a reinforcing feedback cycle by which a culture of harm reduction within law enforcement and the community builds trust and positive relationships. As relationships improve, police become more willing to abide by GSLs, thereby leading to fewer drug arrests that violate the intention of the GSL. This reduction has the potential to improve harm reduction agencies’ belief in the willingness of law enforcement agencies to follow GSLs, which, in turn, further improves the culture of harm reduction and relationships between harm reduction and law enforcement by building trust between the two groups.
The narrative described by balancing feedback loop B5 incorporates constructs from both loops R6 and B4, connecting concepts related to the quality of relationships between harm reduction and law enforcement to police willingness to abide by GSLs, increased community trust in police, and willingness of bystanders to call 911 for overdose assistance. When police show up in response to a 911 call for an overdose and arrest either the overdose victim or others involved, this contributes to a loss of belief among local harm reduction agencies that the GSL is effective. This erodes the culture of harm reduction, damages relationships between law enforcement and the harm reduction community, and can further decrease police’s willingness to abide by the GSLs. The impact extends to the community, resulting in a decreased willingness of bystanders and previous overdose victims to call 911.
Narrative 4 - Bystander Naloxone Use, Community Participation in Harm Reduction, and Cultural Change Towards Carrying Naloxone (Fig. 5)
The final model narrative is embodied by a single reinforcing feedback loop, R7 (Fig. 5a), that shows how cultural change towards carrying and using naloxone is driven by community participation in harm reduction. When naloxone is successfully administered by a bystander to someone experiencing an overdose, this may empower that individual and other witnesses to engage in harm reduction activities such as obtaining naloxone themselves and being trained in how to administer it. As more members of the community choose to become active participants in harm reduction efforts, the acceptability of naloxone use in the community is reinforced.
Policy Agenda
In the final plenary GMB session for this study, we engaged participants in a policy agenda exercise to identify high-leverage policies that interface with our qualitative SD model and discuss the potential intended and unintended consequences of these policies using a feedback perspective. Out of a total of 64 policies and interventions identified by participants during the five GMB sessions, stakeholders present at the plenary session identified nine that they collectively believed would have the greatest potential for curbing the opioid epidemic in CT (Table 1). We distilled these high-impact strategies into four broad policy themes based on the similarity of their impact on the system and corresponding feedback loops: 1) naloxone access & use, 2) community-based harm reduction services & teams, 3) safer drug use, and 4) education to reduce stigma. A list of the specific high-impact strategies and their corresponding policy theme is given in Table 1, along with a list of feedback loops and model narratives impacted by each specific strategy. A full list of policies identified by participants is available in the appendix (S3).
Table 1
Stakeholder-identified policy themes and selected “high-impact” strategies to improve opioid-related outcomes and effectiveness of CT’s GSLs, with interfacing model narratives and feedback loops
Policy Theme | Selected Strategy | Narratives | Feedback Loops |
Naloxone Access & Use | ● “Leave behind” program (i.e., leaving naloxone at the scene of an overdose) | 2, 4 | B2, B3, B7, R3, R4, R5, R7 |
● EMS, fire, & police carrying and administering naloxone | 1 | B1, B2, B7, R1, R4, R5, R8 |
Community-Based Harm Reduction Services & Teams | ● Connecting patients with recovery services as quickly as possible after an overdose | 2 | B3, B6, R3 |
● Recovery navigator program (i.e., pairing someone who has experienced an overdose with a first responder or patient advocate to link patients to services) | 2 | B3, B6, R3 |
● Receiving addiction/social services at the site of an overdose | 2 | B3, B6, R3 |
Safer Drug Use | ● Safe spaces to use | 1 | B1, B2, B7, R1, R4, R5, R8 |
● A smartphone application that alerts others when the application user overdoses | 1, 2, 3 | B1, B3, B4, B5, B6, R1, R2, R3, R8 |
Education to Reduce Stigma | ● Education of new law enforcement & emergency department staff, specifically to reduce stigma & poor treatment of patients | 1, 3 | B1, B4, B5, B6, R1, R2, R8 |
● Engaging new medical trainees to change clinical culture | 2, 4 | B2, B3, B7, R2, R3, R4, R5, R7 |