CONCERNS AN OPIOID ANTIDOTE COULD “MAKE THINGS WORSE”: A Comparison of Belief in Risk Compensation Among Emergency Responders and Treatment Providers Participating in Naloxone Distribution Training Rachel Winograd, PhD; Kimberly Werner, PhD; Lauren Green; Sarah Phillips, MA; Jenny Armbruster, MA Ed; Robert Paul, PhD

Harm Reduction & Risk Compensation Barriers to widespread adoption of naloxone distribution programs include concerns re: Engagement in more dangerous drug use, Decreased likelihood of treatment seeking, Other drug use enabling Aka “Risk Compensation” – a familiar story No evidence of this with naloxone… but still widely believed Coffin et al., 2016; Dwyer et al., 2015; Doe-Simkins et al., 2014; Maxwell et al., 2006; Seal et al., 2005

Purpose  To date, no investigation has examined differences in perceived risk of naloxone-related compensatory behavior across professions, or the extent to which opioid overdose education and naloxone training modifies these concerns. The current study aims to examine the impact of the overdose education and naloxone training provided through the MO-HOPE Project on endorsement of risk compensation beliefs.

Research Questions  What are the baseline differences in endorsement of risk compensation beliefs between Law Enforcement (LE), Emergency Medical Service/Fire Personnel (EMS/FIRE) and Treatment Providers (TxP)? Does overdose education and naloxone training modify risk compensation beliefs? If so, does profession type moderate pretest vs. posttest differences in beliefs?

Methods Participants (N = 894) included Law Enforcement (LE; n = 550), EMS/FIRE personnel (n =135) and substance use/mental health Treatment Providers (TxP; n = 209) all trained through MO-HOPE.   Total Sample Law Enforcement EMS/FIRE Treatment Providers N = 894 n = 550 n = 135 n = 209 M (SD) Age* 40.1 (10.8) 39.2 (9.9) 39.4 (9.7) 42.1 (13.0) Sex* n % Male 631 71.2% 463 85.1% 97 72.9% 71 34.0% Female 248 28.0% 79 14.5% 33 24.8% 136 65.1% Race* White 713 79.8% 460 83.6% 123 91.1% 130 62.2% Black 117 13.1% 50 9.1% 1 0.7% 66 31.6% Multiracial/Other 64 7.2% 40 7.27% 11 8.15% 13 6.20% * Indicates significant group differences for age (F(869) = 5.55; p = 0.004); sex (X2 (886) = 198.83; p < 0.001); and race (X2 (894) = 88.7924, p <.001)

Methods Post-training Assessment Pre-training Assessment Training Assessments included multiple questions to examine: Opioid overdose knowledge Opioid overdose attitudes (readiness, competence, and concern about providing naloxone) *Risk compensation beliefs* Williams, Strang & Marsden, 2013; Winograd et al., 2017

Pre-training Risk Compensation Beliefs Overall significant difference between groups (F(2,883) = 65.99, p < .001) Post hoc analyses revealed No difference between LE and EMS/FIRE in pre-training risk compensation beliefs [Tukey’s Studentized Range (HSD) = 0.49, 95% Confidence Interval (-0.38,1.36)] TxPs reported less endorsement of risk compensating behaviors than LE [HSD = 3.59, 95% CI (2.84,4.32), p < .05] and EMS/Fire [HSD = 3.09, 95% CI(2.09,4.09), p < .05] * * Pre-training Risk Compensation Belief Scores M (SD) Law Enforcement (LE) 15.01 (3.96) EMS/Fire 14.45 (4.35) Treatment Providers (TxP) 11.34 (3.15)

Analysis of Variance in Risk Compensation Beliefs Omnibus ANOVA (F (10, 837) = 110.08, p <.0001)* Significant main effects: Timing of assessment (F (1, 846) = 759.92, p <.0001) Profession (F (2, 845) = 153.94, p <.0001) Significant interaction between profession and impact of training (F (7, 839) = 3.19, p = .042) Pre Post Difference M (SD) Law Enforcement (LE) 15.01 (3.96) 13.60 (4.36) 1.41 (3.28) EMS/Fire 14.45 (4.35) 11.46 (4.35) 3.00 (3.23) Treatment Providers (TxP) 11.34 (3.15) 9.31 (3.12) 2.02 (2.84) Significant difference between all groups for post-test score and for the slope (difference score). *Analyses adjust for group differences in race, sex, and age

Conclusions Results support the existence of profession-specific differences in beliefs in naloxone-related compensatory behavior. Law Enforcement Officers and EMS/Fire expressed more risk compensation beliefs at both time points Endorsement was reduced in each group following training Reductions were greatest among EMS/Fire (then Tx Providers, then LEO).

Future Directions Examine the role of prior naloxone administration on opioid overdose attitudes…and training benefit Bi-directional, cyclical relationship: Experience using it → Less Concern. Less Concern → More likely to use it. Is that why EMS/Fire showed biggest gains? Explore the construct What methods can be used to objectively test it? How does a provider’s belief impact a patient? Is risk compensation “BAD” if naloxone’s around…? How can we use it as a tool in interventions?

Acknowledgments Other members of the MO-HOPE Team: Angie Stuckenschneider Liz Sale, PhD Claire Ward, MSW Kelly Gregory Suzanne McCudden Nicole Browning, LPC Brandon Costerison Grant 1H79SP022118

RC items Opioid/heroin users will use more opioids/heroin if they know they have access to naloxone. Opioid/heroin users will be less likely to seek out treatment if they have access to naloxone. Providing naloxone to overdose victims sends the message that I am condoning opioid misuse. There should be a limit on the number of times one person receives naloxone to reverse an overdose (refers to multiple overdose events, do not count repeated dose administrations during one overdose event). Naloxone is enabling for drug users (i.e., it enables them to continue or increase drug use when they otherwise might not).