One of the sharpest criticisms against making naloxone widely available to people at risk for drug overdose is this: If people have a medicine on hand that allows them to reverse a drug overdose themselves, won't they stop calling 911?
Though no studies exist to prove or disprove this theory (and it would be nearly impossible to conduct such a study), anecdotal evidence does indicate that many people use naloxone to reverse an opiate drug overdose without summoning emergency medical assistance. However, that doesn't mean that naloxone availability causes people to refrain from calling 911. The fact remains that despite well-intentioned laws that protect people who seek help for a drug overdose from arrest or charge, a percentage of people who use drugs will not call 911. Period. They haven't stopped calling 911 because of naloxone. They never called in the first place.
So that leaves two questions
1) Why do so many people still not call 911 despite legal protections?
2) What can be done to change that behavior?
To answer the first question, let's talk a bit about why people might choose not to call 911. We all know one of the reasons: fear of law enforcement. Though most states now have 911 Good Samaritan laws that offer some degree of protection from arrest and/or prosecution to people seeking help for a drug overdose, a lot of folks either don't know about those laws or don't trust them. (I hear people say all the time, "If cops want to arrest you, they find a way...") So many people who use drugs prefer to avoid interaction with law enforcement altogether.
Another reason people are hesitant to call for help is due to past experience with paramedics and hospital staff. Although there are many compassionate, understanding people in the medical field, almost every drug user I know has had at least one interaction with emergency personnel in which they felt judged, ridiculed, or shamed. Many people choose not to call 911 just to avoid the condescension and stigma that may accompany it.
Lastly, there is the financial question. Ambulances and emergency rooms are notorious for high cost. Even if you are lucky enough to have insurance, we are all familiar with the unpleasant surprises of denied coverage, large deductibles kicking in, caps on coverage, etc. So reluctance to call 911 (or to go to a hospital if an ambulance is summoned) often stems from concerns about not being able to afford it.
When most people are deciding whether to call 911 for a drug overdose, they weigh the risks. On one hand, the naloxone might not work or the person might need follow-up medical care (a relatively low risk given naloxone's remarkable safety and effectiveness). On the other, calling 911 opens up the possibilities of arrest (even in a state with a 911 Good Samaritan law), the sting of judgment from a condescending paramedic or hospital staff, and potentially a whopping hospital bill at the end of it. It's no wonder that many people choose not to make that call. In fact, many of them choose other methods of trying to rouse a person such as injecting them with milk, cocaine, or salt water, putting them in a cold shower, placing ice on their groin or other methods that are far more dangerous and less effective than naloxone.
Should people call 911 for a drug overdose even if they give naloxone? Of course. It never hurts to play it safe. That's why every major overdose prevention organization in the country stresses the importance of summoning emergency help even before administering naloxone. But the fact remains that naloxone is safe, effective and in most cases, the patient does not require follow-up care other than monitoring to ensure their condition remains stable. If we want people to take that extra step to keep them safe, we need to reduce the real and perceived risks of calling 911.
Which brings us to the second question: How do we encourage those who are not currently calling 911 to change their behavior?
Well, we have to change our behavior first.
The law enforcement community needs to be more consistent about treating a drug overdose as a medical emergency and not as an opportunity to harass and/or arrest someone for minor drug offenses. Law enforcement and medical personnel should be encouraged to treat drug users with compassion and respect. The more positive the interaction, the more likely a person will call 911 in the future. And something must be done to fix the emergency medical system's warped price tag.
These are not easy reforms. They will take many, many years. But there is good news. Around the country attitudes towards drug use are changing. Many law enforcement departments now carry naloxone and use it to respond to an overdose and save a life. In some EMS programs, paramedics now distribute naloxone to people who have experienced an overdose. Slowly, drug overdoses are being seen less as opportunities to cast judgment and more as opportunities to save lives not only that day, but in the future.
We should continue to encourage people to do the right thing and call 911. But if we really want to change behavior around drug overdose, we need to start doing the right thing too. In the meantime, for those who still fear summoning emergency assistance to a drug overdose, naloxone may be the only tool they have to save a life.