1. 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

2. 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

3. 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.

4. 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?

5. 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) = ; p < 0.001); and race (X2 (894) = , p <.001)

6. 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

7. 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)

8. Analysis of Variance in Risk Compensation Beliefs
Omnibus ANOVA
(F (10, 837) = , p <.0001)*
Significant main effects:
Timing of assessment
(F (1, 846) = , p <.0001)
Profession
(F (2, 845) = , 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

9. 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).

10. 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?

11. 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

12. 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).