A Qualitative Study of EMTs’ Perceptions of Opioid Overdose Reversals With Naloxone

Abstract

In the United States, overdose fatalities involving opioids declined from 83,140 in 2023 to 54,743 in 2024—the largest single-year decline ever recorded and the fewest total drug deaths since 2019. The decline has been attributed in part to expanded access to harm reduction technologies to mitigate addiction and overdose, including expanded access to naloxone. We analyzed data on beliefs about opioid overdose reversals with naloxone among a subset of first responders in Pennsylvania, drawing from qualitative interviews with 20 emergency medical technicians, conducted in the south-central region of the Commonwealth. Participants were asked about their perceptions of the opioid problem, the challenges experienced when administering naloxone and during the pre-hospital phase generally, and their perceptions of overdose patients. Our findings reveal stigmatizing beliefs about patients who experience overdose and highlight the need for further education on naloxone's role in mitigating opioid-involved overdose regarding three principal areas: polydrug use and drug myths, recalcitrant patients, and iatrogenic harms/system-related deficits. We conclude by discussing the implications of these findings for education efforts directed toward first responders.

Introduction

The United States continues to experience the highest rate of drug overdose deaths globally, with some three-fourths of these deaths involving synthetic opioids, principally fentanyl (Centers for Disease Control [CDC], 2022). After rising steadily for over a decade, drug overdose deaths accelerated sharply around 2012 and rose precipitously in 2020, following the widespread issuance of stay-at-home orders in response to the COVID-19 pandemic. Overdose deaths peaked in 2022 at roughly 108,000, with 76% involving an opioid (CDC, 2024). Recent data show that drug overdose deaths declined by over 26% in 2024—representing the largest year-over-year decline ever recorded and the fewest total deaths since 2019, with opioid-involved overdoses declining from 83,140 in 2023 to 54,743 in 2024 (CDC, 2025). Some attribute the historic decline to a broadening embrace of harm reduction and public health approaches, including expanded access to medications for opioid use disorder (MOUDs) like buprenorphine and methadone, wider availability of fentanyl test strips, and propagation of the overdose reversal drug naloxone to reverse opioid-induced respiratory depression (Drug Policy Alliance, 2024). Others argue more critically that the decline simply constitutes a regression to the mean before COVID-19 closures artificially inflated the number of overdose decedents by reducing access to treatment, coupled with an increasingly unreliable drug supply (McAdam et al., 2022; Mobilize Recovery, 2025). Whatever the case, it is clear that naloxone continues to occupy a crucial niche in addressing the opioid overdose problem.

First approved by the U.S. Food and Drug Administration (FDA) in 1971, naloxone was kept tightly limited by organized medicine until being gradually extricated by harm reduction activists in the 1990s. Access to take-home naloxone (THN) was first facilitated in Turin, Italy, in 1991 (Campbell, 2019). In the U.S., the Chicago Recovery Alliance began distribution of naloxone to persons using syringe services in 1996, scaling up their operation such that by the late 1990s, it was the premier clearinghouse for THN distribution nationally (Campbell, 2019). In the United Kingdom, THN was first considered as a formal public health strategy in 1996 with pilot programs introduced in the British Channel Islands (Dettmer, Saunders & Strang, 2001) and was formally incorporated into the U.K. Medicines Act in 2005 (McDonald, Campbell & Strang, 2017). In 2011, Scotland became the first nation to adopt THN as a formal public health policy and was the first to introduce naloxone to frontline workers, including police officers in 2022 (Speakman et al., 2023).

In the United States, the police department in Quincy MA was the first to require officers to carry naloxone in 2010 (Coppola, 2014) ¹ . With the approval of the naloxone nasal spray device by the U.S. FDA in 2015 and the waiving of prescription requirements in some U.S. states, layperson access and police officer carriage was further broadened (i.e., PA Act 139; Speakman et al., 2023). The FDA approved over-the-counter intranasal naloxone (Narcan) in March of 2023. ² In summer 2023 the FDA approved a second nasal spray naloxone device (RiVive). A generic equivalent (Amneal) was made available in spring of 2024. Despite increased funding for drug treatment in some localities after the first disbursements of opioid settlement money in 2024, comprehensive addictions treatment remains elusive for many, and propagation of nasal spray naloxone has been scaled up to fill the gaps (Kavanaugh, 2022).

First responders are generally defined in the literature as paramedics, emergency medical technicians (EMTs), firefighters, and police officers. All have the potential to play a significant role in reversing opioid overdose in the field (Davis et al., 2014; Fisher et al., 2016; Wermeling, 2013). Delivering optimal patient care and aftercare, however, is often hampered by social stigma. In this study, our aim is to contribute to the developing literature on provider-based stigma by querying perceptions of overdose reversals with naloxone in a sample of EMTs working in an area of the U.S. mid-Atlantic where the opioid problem remains protracted.

Stigma and First Response

Erving Goffman's seminal work on stigma conceptualizes it as “an attribute that is deeply discrediting” (1963, p. 3) … and “that links a person to an undesirable stereotype, leading individuals to reduce the bearer from a whole and usual person to a tainted, discounted one” (1963, p. 11). Stigma has since been subject to extensive theoretical elaboration. In the context of the opioid crisis, researchers have highlighted four dimensions of stigma experienced by persons with opioid use disorder (OUD): (a) perceptions of dangerousness (they are a threat to self and others due to their condition), (b) blameworthiness (they are to blame for their condition), (c) fatalism (they will never recover from their condition), and (d) social distance (they are to be avoided due to their condition) (Kaynak et al. 2022; Kruis et al. 2020; Perry et al. 2020; Pescosolido & Martin, 2015; also see Link & Phelan 2001). This research has highlighted substantial provider-based stigma, with hospital personnel and first responders often expressing deep ambivalence or reticence regarding the use of harm reduction technologies such as naloxone (Bessen et al., 2019; Kruis et al., 2022; Rudski, 2016). In specific, there is a belief that expanded naloxone access and use might embolden opioid users, encouraging irresponsible or risky styles of drug use, discourage treatment, and fail to address underlying social and behavioral drivers of opioid use and addiction.

Research is inconsistent regarding how different subsets of first responders regard nasal spray naloxone, and studies often combine or conflate multiple professions in their sampling designs (i.e., Kruis et al., 2022). Given that first responders span at least four professions, there is substantial variability in how overdose reversals are handled that often reflect the medical knowledge of a given profession. Paramedics have the highest levels of certified training. EMTs are certified at a “basic” level. Firefighters and police are not usually certified but sometimes take courses on recognizing an opioid overdose and administering naloxone. Accordingly, paramedics are more likely to correctly identify adverse effects like confusion, agitation and combativeness as resulting from hypoxia, whereas those with less training—such as police officers, are more apt to interpret such behavior as anger about naloxone having “ruined their high.” While research has found that police can administer naloxone to reverse opioid overdose (Fisher et al., 2016), several studies have found that police often hold more negative attitudes about naloxone than those working in emergency medicine (Berardi et al., 2021; Carroll et al., 2020; Kruis et al., 2020; Murphy & Russell, 2020). Research has also found that when police respond to an overdose scene, they are equally likely to make an arrest as they are to administer naloxone (Elliott et al., 2019).

Other studies suggest EMTs and paramedics hold equally negative attitudes as police officers, despite having greater medical knowledge around naloxone, toxicology, and drug addiction (Kilwein et al., 2019; Pike et al., 2019; Williams-Yuen et al., 2020; Wright et al., 2019; Zhang et al., 2018; Zozula et al., 2021). While naloxone is correctly perceived as a potentially lifesaving drug intervention, emergency medical personnel have articulated systemic frustration around beliefs that naloxone does not treat the underlying addiction. Several studies have examined barriers to naloxone acceptance among EMTs, as well as concerns regarding their safety in treating overdoses, and found that the possibility of recalcitrance and violence after naloxone administration significantly dampened their enthusiasm (Bessen et al., 2019; Davis et al., 2014). Research on emergency medical service providers and staff has also found that “compassion fatigue” or “burnout” is prominent among them, with the hope of using an overdose as a turning point for addictions treatment or rehabilitation regarded as unlikely (Elliott et al., 2019; Saunders et al., 2019).

Despite a growing body of research on first responder perspectives on naloxone and overdose reversals generally, fewer studies have looked at the perceptions of EMTs as a discrete profession. Fewer still have unpacked subjective perceptions of naloxone encounters and naloxone's incorporation into the broader state response to the opioid problem. Accordingly, in this study, we query EMTs’ experiences with naloxone to reverse opioid overdose, perceived issues and complications, and their beliefs about how naloxone fits into the broader treatment landscape.

Data and Methods

The study received Institutional Review Board approval from the Pennsylvania State University in 2019. Participants with at least one year of experience working as EMTs were invited to participate in the research. Participants were employed as EMTs in various emergency medical agencies in the commonwealth of Pennsylvania (n = 20), principally in the south-central region (n = 16). The remaining four were in adjacent counties (n = 4). Participants were identified using a convenience/snowball sampling technique and were recruited through referrals from staff within participating agencies. All participants were asked the same questions with a few interruptions from the researcher, except to clarify questions, ask for elaboration, or probe for follow-ups. All interviews were conducted in the winter of 2020 (January through March). Interviews were semi-structured, thereby allowing for exploration of topics not anticipated by the researchers.

The sample group was comprised primarily of Basic and Advanced Life Support (ALS) EMTs (n = 17). Three were paramedics. Participants ranged in age from 22 to 63 years, with a mean of 12 years of working experience. Senior paramedics/leadership participated in the research study as key informants and introduced the researchers to EMTs. Those interested in the study were given an informed consent form and then participated in a recorded interview. Interviews ranged from 30 to 60 min with a mean interview time of 48 min. Interviews focused on EMTs experiences with opioid-involved overdose, naloxone administration as well as their perceptions of the state response to the opioid addiction and overdose problem. Interviewing consisted of queries about participants’ overall experiences and invited comment on overdose management policy more broadly.

All interviews were audio-recorded and transcribed verbatim by the first author. Transcripts were de-identified using pseudonyms and uploaded into NVivo 12 qualitative analysis software. Data were then analyzed using reflective thematic analysis (Braun & Clarke, 2022) derived from an inductive coding process. Transcripts were analyzed for both manifest (directly observable) and latent (implicit) content. The first author developed the coding framework based on the interview guide and sorted respondent quotations into a preliminary list of codes. The authors then met weekly to merge and refine codes over a period of 6 weeks following completion of interviews. The authors then condensed the codes into broad themes. Interview transcripts were then re-read by the first and second author to ensure the themes accurately reflected the patterns identified in the data during the coding process.

Findings

The 20 interviews with emergency medical personnel provided insight into perceptions of naloxone administered in overdose reversal situations across three main themes: the first two pertained to patients; the third pertained to structural and organizational problems in emergency medicine and hospital care. The three themes that orient our findings are as follows: (a) polydrug use and agitation, (b) treatment resistance, and (c) iatrogenic harm.

Polydrug Use and Agitation

Participants indicated that patients were often confused as to why they overdosed, and when respiratory depression is reversed with naloxone, they resume the effects of whatever other drugs are in their system. Non-opioid users who were using cocaine or methamphetamine were treated for opioid overdoses because their drugs were adulterated with cheaper synthetic opioids. The following excerpt is illustrative:

A lot of opioids, K2, cocaine, methamphetamines. Cocaine users are lumped into because of supplier adulterating fentanyl into coke. We’re seeing more, different types of illicit substances in the mix now. No way of doing toxicological review in the field. Something we can look at once the patients at the hospital. We don’t know what we’re getting when we get there and look at their symptoms. We’ve had people mix [opioids] with alcohol, or Xanax, you name it. Unless it is on the scene.

Participants further cited challenges with the unpredictable nature of overdoses, especially those resulting from presumed polydrug use in patients. This presented a challenge to EMTs, in that patients would often be experiencing ongoing effects of other drugs following naloxone administration. This was especially a complication with depressant drugs like benzodiazepines. As one EMT described:

If it's someone who's using opiates and benzos, the Narcan counteracts the opiates but not the benzos. You may not even be able to wake them up if they’ve gone unconscious. As far as I know there's nothing like Narcan for benzos.

However, most of the participants cited synthetic substances (fentanyl analogues) and synthetic cannabis as the most frequently encountered combinations. Some EMTs referenced a link between polydrug use and violence when treating overdose patients:

Whenever we have patients using synthetics with the opioids, they become very violent. The Narcan will take their high away and they’ll get angry at us or then Narcan will work but then you have a patient high on synthetics, particularly synthetic marijuana. That's one of the main one's – they’ll use K2 and opioids at once. When you wake them up, they become superhuman.

Participants were asked about safety concerns associated with responding to opioid overdoses. Many indicated that patients in withdrawal would “come up combative,” especially if they were believed to be under the influence of other drugs.

Yeah, we’ve had at least five employees last year get injured on two separate calls. It was an OD who was out of control. On one, law enforcement was struggling to control the patient, they asked the paramedic to check if he was breathing, got too close and would up getting injured. Officers were not injured. Not usually common for staff to get attacked like this. They may deny they took anything, might be upset because they were in recovery. In both these cases, there may have been polypharmacy going on.

It was also noted that often police were on scene prior to Emergency Medical Services to manage safety concerns. The following exchange is illustrative:

Interviewer: Any safety concerns when administering naloxone?

EMT: Not really to be honest with you. Police usually come on those calls with us, usually the only safety issues are with someone who has polypharmacy and gets agitated and combative, once you wake them up, they can get dangerous. But usually we have police assistance, the state allows us to use ketamine now for chemical sedation, usually if we have a bad patient, we will chemically restrain them, I do not think there are many safety issues to be honest with you.

The narrative excerpt here further references the presence of the police, for threat management, and the use of chemical sedation with ketamine—a dissociative anesthetic with potent sedative properties and a high rate of causing respiratory distress—as simply a tool in the toolkit for EMTs or other first responders engaging with “bad” patients. ^{3 , 4}

Treatment Resistance

Barriers to effective risk-reduction or opioid use cessation were considerable and articulated among almost all the EMTs in our study. For example, participants often indicate trouble encouraging patients to go to the emergency department at the hospital after naloxone was administered and consciousness was restored to their patient. While it is official policy in Pennsylvania to transport overdose patients to the hospital, many sign out shortly after arriving.

I think a lot of these people just choose not to [accept further help]. We offer them counseling and rehab at the hospital. They leave, sign out and deny even using. I would respond to patients, and they will deny having overdosed at all. A lot of people don’t want to get the help.

Participants often indicated feeling discouraged, despite their consistent efforts at providing users with treatment resources, and characterized their attempts to prompt further patient help-seeking as futile.

EMTs commonly expressed a lack of empathy toward overdose patients in our interviews, with one participant referring to the phenomenon as “compassion burnout”—a topic on which there is also an established and growing literature (Elliott et al., 2019; La Manna et al., 2025; Mamdani et al., 2024). Such feelings were expressed across 17 of our 20 participants. The following two excerpts capture the complexity of empathy deficits:

I honestly have no clue what to do for them other than wake them up. I personally have lost most of my compassion for them because of these repeat offenders, the drug is just so strong it takes over. I’m not sure what government or EMTs can provide. It has to go much farther than Narcan.

Another EMT expressed a more sympathetic view:

The personal [stigma] of [overdosing], these people get shit on just by the public “oh you’re a shitty drug addict” or you take them to the hospital, and they just want to get them out of there. There's not as much empathy for these folks which is sad and hurts me the most. It sucks because from my perspective, I’ve seen and worked with people in recovery. Anybody who's an addict will be in recovery for the rest of their lives, it takes a lot of support counseling and work. Seeing where they’ve come from blows my mind. I personally have a lot of empathy because I know they have a problem. I get frustrated, especially for repeat offenders. I do the work and use my network to get them help and 2 weeks later I’ll be treating them for an overdose again.

In the excerpt here, the blame is placed equally on the patient as offender, the State as absent, and healthcare systems as sites of stigma. Several EMTs in our sample referred to this variant of patient pejoratively as “frequent flyers” and bemoaned their significant drain on EMS resources.

To some extent, for the folks we see on a routine basis. There are a number of people you begin to know by name, you’ve seen them so often. That percentage of the population uses EMS and Narcan as a safety net. Some of the other ones not so, just enabling among the frequent flyers.

Many of our participants appeared to support a bifurcated view of opioid addiction, endorsed a “get clean” imperative, and expressed frustration if the overdose reversal could not be leveraged toward a sustained commitment to treatment and abstinence. If patients did not comport to this normative ideal, they were often regarded with some degree of derision. Sometimes this was expressed in more detached and practical terms, as repeat overdose patients siphoning resources that could potentially go to other patients constructed as comparably more worthy and deserving of medical resources:

If the patient is in cardiac arrest, it can take an hour or two hours depending on how quickly you found them and what state they were in. With those quick calls, there's times of the day where we get 4–5 calls at once, you’re tied up with an overdose, and a cardiac arrest might come in that might be missed. It's more frustrating in those cases, especially with repeat overdoses.

Iatrogenic Harm

Another theme uncovered in our interviews revealed frustration with how naloxone inadvertently causes harm to patients. The following excerpt is illustrative:

They don’t want to go to the ED, they’re itching to use again because they are in clear withdrawal. If we give them sufficient quantity to wake them up we took away their high. They went from 10 to 0. They are angry, pissed off, sometimes fighting mad. Sometimes they don’t want to go to the ER because they know they have to get high again because their skin's crawling…

The EMTs in our sample were using the intranasal 4 mg multidose atomizer (brand name: Narcan), given to first responders across the Commonwealth via a grant from the Pennsylvania Commission on Crime and Delinquency (PCCD). A small number (n = 2) of the paramedics in the sample expressed a more nuanced understanding of the dosing complications with the proliferating variations of naloxone formulations. The following excerpt is illustrative:

Respondent: *shows interviewer one of their 4 mg intranasal Narcan kits*

Interviewer: Was that given to you by the Department of Health?

Respondent: Yes sir.

Interviewer: Is it specified in your protocol?:

Respondent: It is not specified in the ALS protocol, something that's being dealt with at the state department of health. With the auto-injectors you can’t control the full dose, where our ALS protocols indicate up to a certain amount, so the auto-injectors go over what we are allowed to do. The direction we’ve received form the regional government says ‘use what you have because you’re saving lives’. And that auto-injector Narcan has come through PCCD grants.

Another EMT described the complications with 4 mg formulations of nasal spray naloxone:

[A lot of the problems] stem from high amount of Narcan use. We are taught to titrate—that's a medical term for pumping air into the body—to respiratory effort, but some people push Narcan until they wake up. This happens frequently, which is when they will have violent outbursts. Or they will go into withdrawal. Vomiting, god-awful pain, which is not the goal at all. We should be titrating to respiratory and let the hospital deal with that. As much attention as this has gotten, it's a misused drug.

Several participants expressed their belief that police officers exacerbate these issues. Many have indicated that their local police departments are often untrained in naloxone administration, and patients are suffering adverse effects due largely to not being properly oxygenated, which can keep naloxone from working. The following excerpt is illustrative:

We’ve tried to train local PD on this. What you can find is that a lot of them do not want to give medication. I think a $3 ventilation mask to assist respiratory drive is enough. If that person is in cardiac arrest, you’re not supposed to give Narcan. They might run into someone who is unresponsive, pinpoint pupils, drug paraphernalia on the scene and will push Narcan, typically they are right to do so. But they’ll just give it—and a lot of it—just because that's what they’re taught to do.

EMS providers also expressed frustration regarding the broader availability of addiction treatment. Many participants indicated a lack of adequate rehabilitation facilities that meet the needs of their clients. Of the ones that exist, lengthy wait times, lack of beds, and financial burdens were cited as barriers. The following excerpt is illustrative:

Sometimes when you’re seeking help with addiction, you’re better off not having insurance. Some places will keep you because they know the state will reimburse them, but with insurance they can only keep you if your insurance is paying for. I think some of the barriers are, if it's someone who has a job and they need to go away for a month to get treatment, they have to worry if they’ll be able to keep their job. So, there's financial barriers, probably some cultural as well, if you’re younger and around people who are using drugs and you want to seek help, that may not fit into the way you want your group of people to see you.

Discussion and Interpretation

The experiences and perspectives of our participants support prior findings uncovered in qualitative first responder naloxone encounter studies, as well as some novel findings—particularly around encounters with polydrug-using patients. Before turning to our themes, it is worth acknowledging an analytic tension running through the data and interpretation of it: we are simultaneously offering a critical reading of the stigmatizing attitudes EMTs hold toward overdose patients and a sympathetic reading of EMTs as workers embedded in a structurally broken system. We regard this as a “both/and” rather than an “either/or” situation. EMTs are not just stigma-bearers to be criticized; they are practitioners operating under conditions of chronic under-resourcing, inadequate training around drug use and addiction, and an opioid crisis that has long outpaced the systems intended to mitigate it. At the same time, structural conditions do not fully account for, nor excuse, the punitive attitudes and quasi-criminal framings observed in our data. Both dimensions deserve attention, and we carry this dual orientation through our interpretation.

As reflected in our first theme around polydrug use and agitation, those in our sample often invoked commonly held drug myths about their patients that contributed to stigma. This was clear in their belief that polydrug use inevitably imbues patients with exaggerated levels of physical strength. Scholars have long observed how the “superhuman drug user” trope has been a staple in popular understandings of drug use, from the so-called “negro cocaine fiends” (Williams, 1914, p. 48) in the U.S. South in the early 1900s (Cohen, 2006; Musto, 1987), to the videotaped beating of Los Angeles motorist Rodney King in 1991, neutralized by the Los Angeles Police Department with speculation that he “may have been dusted” (on phencyclidine) (Baker, 1993, p. 42), to more recent “bath salts zombie” rhetorics, leveraged to obscure police killings of unarmed suspects (Linnemann et al., 2014).

We observed that EMTs would sometimes employ similar tropes to make sense of recalcitrant patients encountered in the course of their work. For our interviewees, recollections of recalcitrant patients following naloxone administration facilitated the expression of legitimate anxieties about overdosing and polydrug use—a fear of the unknown. In the high-stress context of emergency rescue, where mistrust between drug users and EMTs already exists, it would only take a few antagonistic administrations to create a received wisdom that fuels negative expectations on the part of EMTs (Neale & Strang, 2015). In several instances, this led to the endorsement of punitive practices, such as the forceful restraint and sedation of “bad” patients who do not comport with a docile normative ideal. Taken together, the polydrug use and agitation data reveal a “bad patient” construct that maps onto the dangerousness and social distance dimensions of the elaborated stigma framework: overdose patients are constructed as threats requiring physical management and as persons to be kept at arm's length or discharged quickly rather than engaged with compassionately.

In our second theme regarding treatment resistance, we can observe a further endorsement of stigmas around drug users and perceptions of blameworthiness on the part of EMTs. A number of those in our sample invoked the notion of patients as “repeat offenders” in the two excerpts above, revealing a punitivity in how patients who experience relapse and subsequent overdose are regarded. Here, our findings align with some prior research on first responder perceptions, including police (Bessen et al., 2019). Calls from patients viewed as “frequent flyers” or “repeat offenders” also reveal perceptions of recalcitrance and lack of help-seeking by the patient. “Repeat offender” is a phrase borrowed from the criminal-legal system and denotes a habitual wrongdoer unresponsive to arrest or imprisonment. “Frequent flyer” originated within first responder culture, intended as levity or dark humor (Kavanaugh, 2022). The phrase carries an implicit judgment that such patients are a drain on EMS resources and a distraction from more legitimate emergencies—the subtext being that an overdose patient cycling through the system is less deserving of care. Together, the phrasings reflect a framing of overdose patients less as persons requiring care than as bad actors. Read through the elaborated stigma framework; this language activates the blameworthiness and social distance dimensions, marking patients as responsible for their condition and as persons from whom emotional distance is warranted.

Prior studies have also shown that failure to influence patients to seek treatment is strongly connected with burnout and loss of job satisfaction (Elliott et al., 2019; Saunders et al., 2019). While there is an emerging literature on how perceptions of oppressive surveillance practices in hospital or mainstream healthcare deter further help-seeking post-overdose (Guta et al., 2021; Michaud et al., 2023), only one of the 20 EMTs we interviewed was attuned to these kinds of concerns among patients. Recent research around harm reduction has emphasized the importance of compassionate reversals, which focus in part on post-overdose care, such as helping the patient get oriented and attending to immediate physical needs, rather than immediate conversations about treatment referrals, misinterpreting patient confusion and memory loss as lying, and so forth (Neale et al., 2020; Parkin et al., 2020; Russell et al., 2024). Our findings here further support incorporating compassionate responses into repertoires of care to potentially improve provider–patient relations and encourage naloxone uptake (Farrugia et al., 2019).

Regarding our third theme around naloxone protocols and iatrogenic harm, our participants made technical, critical comments about naloxone dosing and the potential for causing precipitated withdrawal in patients. In hospital settings, naloxone is first administered in a low dose, then titrated to optimize reversal of opioid-induced respiratory depression without restoring consciousness or leading to precipitated withdrawal (Lynn & Galinkin, 2018). Out of the hospital, titrating naloxone is impractical, so a standardized (4 mg) intranasal dose given in an emergency rescue context is the propagated form. Multiple references to “waking up” patients in the excerpted narratives are illustrative of this. Moreover, several EMTs indicated being required to use larger doses of naloxone when treating a potential fentanyl overdose. It is important to emphasize that issues pertaining to dose and dosing—by people—cause iatrogenic harms such as precipitated withdrawal and general agitation, not naloxone itself. Recent research based in New York City (Parkin et al., 2020; 2021) and Australia (Farrugia et al., 2019) both underscore that a key dimension of compassionate reversals beyond exhibiting patience and sensitivity during the post-revival period is appropriate dosing. As Russell et al. (2024) remind, “opioid withdrawal is a life-threatening concern among people who use drugs and should be taken seriously by first responders, medical providers, regulatory agencies, pharmaceutical manufacturers and lay responders” (p. 3).

Despite fentanyl analogues currently dominating the North American opioid supply, medical researchers have studied the 0.4 mg intravenous protocol and the 2 mg intranasal protocol and found both to be effective at treating overdose patients who tested positive for opioids, including stronger synthetics (Jalal & Burke, 2022; Thompson et al., 2022). While recent research has shown that larger doses of buprenorphine are beneficial for MOUD treatment in the context of the current fentanyl-dominant opioid supply (i.e., Stringfellow et al., 2025), administering naloxone in large doses or administering multiple doses can be harmful (Farah, 2021; Hill et al., 2022; Lemen et al., 2024; Russell et al., 2024). The dosing issue has also been shown to exacerbate mistrust and negative regard between patients and first responders (Chhabra & Aks, 2020). Compassionate reversal practices—especially dosing awareness—have the greatest potential to reduce angry responses and improve provider–patient relations.

Conclusion

As our findings show, first responders need a reasonable amount of medical training before they can optimally manage opioid overdoses. Research suggests that first responders, such as police officers, want harm reduction training (Rudisill & Mohamed, 2025), and we find the need for training for first responders working in emergency medicine as well. We have a few specific recommendations.

First, we suggest that debunking drug myths be incorporated into education and training programs, and that understanding the causes of patient agitation, incoherence, or general recalcitrance be contextualized so that EMTs are not creating a negative bias by relying on cultural tropes about drug use, drug effects, and addiction. For example, in response to viral myths about passive fentanyl exposure, a recent training session in our Commonwealth led by a pharmacy professor from a local university worked to dispel popular beliefs about transdermal toxicity or aerosolized fentanyl overdose for paramedics and firefighters (Kress, 2023). Our findings suggest the need to scale up such training, as well as to incorporate material on other drug myths, especially around polydrug use. Most opioid overdoses involve other drugs like alcohol and benzodiazepines, and in the mid-Atlantic United States, the veterinary tranquilizer xylazine is a common adulterant (Russell et al., 2024). Polydrug overdose is the rule, not the exception, and dispelling misinformation around it is critical. Additionally, training should draw EMTs’ attention to the judgments embedded in everyday professional language—phrasings like “repeat offender” and “frequent flyer” are not clinical terms and making practitioners conscious of the stigmatizing work such language performs could be a meaningful, low-cost complement to these efforts.

Relatedly, many EMTs in our sample expressed the view that naloxone given to patients in an emergency, rescue context means administering multiple doses that are already stronger than medically necessary. First responder education should incorporate information on what naloxone can do (reverse overdose) but also emphasize that “waking people up” can precipitate withdrawal—and with it, increased risk of agitation, relapse, successive overdose, and reluctance to call for medical help in future emergencies. To counter this, we echo the sentiment that drug users should be more directly involved in decisions regarding the distribution and training of opioid overdose reversal products (e.g., Russell et al., 2024). We further suggest that while the 4 mg intranasal spray version is the most widely available application, that it can also cause iatrogenic harm (Lemen et al., 2024). One recommendation is to advocate for pivoting back to injectable naloxone, titrated optimally without consciousness restoration, before handing them off at hospital. We acknowledge however that given the ease-of-use of the 4 mg intranasal spray, and recent access to lower-cost 4 mg generics, such a move is unlikely.

Finally, our participants often acknowledged they are working as part of a system that is incapable of managing overdose patients comprehensively or according to their individual needs. We concur with prior research suggesting that first responders need to perceive themselves as an integral part of a broader interconnected system of care and that this would help alleviate some of the negativity those in our sample expressed toward overdose patients (Mendoza & Holmes, 2023). One way to accomplish this is to help EMTs view themselves as agents of harm reduction operating somewhat outside of the medical establishment, or as a sort of middleman between the patient and the formal system. This would necessarily involve revising definitions of successful overdose reversals to emphasize the gentle restoration of breathing, avoiding withdrawal, and providing compassionate post-overdose support. We believe educating EMTs around these ideas will help them to develop a deeper understanding of naloxone's potential, dangers, and a realistic grasp of their professional role in affecting larger change around overdose.