Study design and sample
The present study is part of a larger feasibility study that aimed to assess the acceptability of OEND programs in rural Appalachia. From August 2014 to March 2015, participants were recruited from three neighboring counties in southern West Virginia. These counties were selected as sites for recruitment based on their elevated rates of unintentional drug overdose fatality and the availability of community partners for collaboration. Eligibility criteria included being at least 18 years of age, currently residing in one of the three target counties in southern West Virginia, and reporting non-medical use of prescription opioids at least five times in the previous 90 days. Participants who consented to participate in the study were compensated with one $25 gift card for their time and one $10 gas card for transportation. This study was approved by the Institutional Review Board at West Virginia University.
We consented and enrolled 169 participants who met the eligibility criteria for the pilot study. Among those, 73 (43%) reported that the most recent overdose they witnessed involved prescription and/or illicit opioids. Individuals indicating that the most recent overdose that they observed did not involve opioids (96, 57%) were excluded from the present analyses, as the aims of the current study are specific to witnesses to opioid-related overdoses.
Recruitment
Respondent-driven sampling (RDS) was used to recruit participants. RDS is an effective sampling technique that is commonly used to access hidden populations (16–19). RDS has been successfully implemented to recruit a sample of participants who use stimulants in rural Ohio (19) and a sample of people who predominantly use prescription opioids non-medically in rural Kentucky (20). For this study, community partners who resided in the target counties were trained to recruit and interview participants. To recruit the first “wave” of participants, these trained community partners first identified “seeds” through a variety of methods, including convenience sampling of persons enrolled in treatment for substance use disorders and by drawing on personal social networks to identify potential participants.
Once participants were screened, the trained community partners conducted structured, in-person interviews in private and semi-private natural settings, including private offices and participants’ homes. At the completion of the interview, each participant was provided two referral coupons to distribute to eligible peers. For each referral coupon that was redeemed, the referring participant was compensated with one additional $15 gift card for up to two additional participants recruited. Referred participants who completed the interview were also invited to refer their peers to the study, and so forth, until several recruitment “chains” comprised of multiple waves of recruits were produced.
Measures
Data were collected through paper and pencil interviewing and were later entered by study personnel into a secure web-based database (Research Electronic Data Capture [REDCap], version 6.0.3, Vanderbilt University). Measures included sociodemographic characteristics, experience with witnessed overdose (lifetime and prior year), personal experience with nonfatal overdose, characteristics of the most recent witnessed overdose, responses to the witnessed overdose, and OEND acceptability.
Sociodemographic characteristics, such as age, gender, and education, were assessed using conventional items. To measure lifetime witnessed overdoses, participants were asked “Have you ever witnessed a drug overdose?” Drug overdose was defined through the following structured priming: “When a drug overdose occurs, a person’s skin, lips or fingers may turn blue; their breathing slows down and may stop; or they may nod off and cannot be woken up.” If an affirmative response to the item was provided, participants were then asked the number of overdoses ever witnessed and overdoses witnessed in the past year, the date of the most recently witnessed overdose, where the event occurred, the respondent’s relationship to the victim, the number of people present at the overdose event, the observed substances used by the victim prior to overdose, the victim’s symptoms (e.g., unresponsiveness), and the respondent and others’ response to the overdose (e.g., called 911).
To measure the respondent and others’ response to witnessed overdoses, participants were asked “What did you or others do to respond to the overdose?” As participants provided responses to this open-ended question, the trained interviewer selected from a pre-determined list of responses on the interview form. If none of the pre-determined potential responses were provided, interviewers would check other and record the response (as close to verbatim as possible). The pre-populated list of potential responses on the form included nothing, yelled at them, hit or slapped them, rubbed them with ice or put them in a cold shower, rubbed knuckles on their chest, walked them around, did CPR or rescue breathing, moved them into recovery position lying on their side, injected milk or salt into them, injected cocaine or methamphetamine into them, administered naloxone, called 911, and other (i.e., text entry field for respondent-generated other responses). Response options were informed by prior literature (21). Participants were also asked “Did you or anyone stay with the person until he or she recovered or professional help arrived?” Responses to these two questions, as well as respondent-generated other responses, were then categorized as appropriate or inappropriate based on previous studies that assessed OEND efficacy (21–26) and current overdose response strategies endorsed by the National Harm Reduction Coalition (27). Participant responses were then categorized as “all appropriate responses” (i.e., only appropriate responses) and “any inappropriate response” (i.e., at least one inappropriate response); similar characterizations have been applied in previous studies (28).
To assess acceptability of OEND programs, participants were asked at the end of the interview whether they had ever heard of an overdose prevention training program, whether they had ever been trained in an overdose prevention program, and whether they would be willing to participate in this type of program. Overdose prevention programs were defined through the following structured priming: “Opioid overdose prevention programs exist in other areas such as big cities like New York and Chicago and other states such as New Mexico. These programs require a 20–40 minute training session that teaches participants about how to prevent an overdose, how to recognize an overdose, best actions to take when someone is overdosing, calling 911, how to perform rescue breathing, the rescue medication naloxone, and practice using naloxone. Because opioid overdose can be life-threatening, anyone who uses opioids (with or without a prescription) or anyone who comes in contact with people who use opioids (like friends or family members) can benefit from overdose prevention training.”