Abstract
Objective
Overdose Response Hotlines and Apps (ORHAs) are novel technologies designed to avert fatal overdose associated with solitary use of illicit substances. While they can be a useful tool for those who cannot reach in-person harm reduction support, previous literature has cited potential barriers to their access. The aim of this study was to quantitatively evaluate the types of barriers that may hinder the uptake and utilization of ORHAs from the perspective of key stakeholders.
Methods
The current study reports on the data obtained from Canadian National Questionnaire on Overdose Monitoring (CNQOM) focusing on people who currently use substances (PWUS-C), have used substances in the past (PWUS-P), and addiction service providers (ASP). A combination of purposive and representative sampling was used for recruitment. A list of potential partner organizations across Canada was contacted between July 2022 and May 2023. We explored logistical, technological, and social barriers to assess the acceptability of ORHAs.
Results
A total of 971 participants were included in this study, consisting of 268 PWUS-C, 525 PWUS-P, and 178 ASP. Barriers to ORHA were categorized into: service delivery and quality barriers, technological barriers, and stigma/social barriers. More than half of the respondents across all groups rated the barriers as 4 (significant) or higher on the Likert scale. Ordinal logistic regression revealed that being an ASP was associated with higher likelihood of rating certain barriers as more significant compared to PWUS-C and PWUS-P.
Conclusion
This study is the first to quantify concerns about potential barriers to the use of ORHAs from the perspectives of key Canadian interest groups and provide valuable information on how to improve accessibility and utility of overdose prevention technologies to a wider range of demographics.
Introduction
Maintaining robust continuity of care and seamless service integration for people who use substances (PWUS) remains an ongoing challenge.1–3 In Canada, the unprecedented rise in fatal opioid overdoses and other harms associated with substance use have necessitated various harm reduction solutions, including supervised consumption sites (SCS).4,5 While these facilities have demonstrated effectiveness in preventing overdose deaths, reducing blood-borne diseases, and improving access to other social and health services,5–7 they may not be practical for many PWUS who reside in rural areas, lack transportation, or live in jurisdictions that do not support these types of facilities.8,9 Given the extent of the overdose crisis, there is an urgent need to diversify the means of providing accessible overdose prevention services to this demographic.
Overdose Response Hotline and Applications (ORHAs) (also known as mobile overdose response services, virtual overdose monitoring services) are a set of novel technologies that offer supervised consumption over a hotline, app, or other virtual communication modalities to those who use substances alone.10–12 The National Overdose Response Service (NORS) is one example of ORHA that operates a 24/7 hotline service in Canada.13,14 When a client reaches out to NORS, a designated operator monitors the client’s consciousness until they are safe to disconnect from the line.13,14 If the client becomes unresponsive, a pre-planned emergency response is initiated, which can involve calling emergency medical services (EMS), friends, or family.14,15 Similar services in the United States include SafeSpot and Never Use Alone, which have similar scope and mission to provide virtual supervised consumption to deter solitary use of substances.16,17 Past qualitative studies on NORS have revealed that its high engagement with PWUS may be due to its recruitment of peer operators who have lived or living experience with substance use. 18 Other services come in the form of countdown overdose response applications for use on mobile smart devices. Apps like LifeguardConnect and the Digital Overdose Response Systems are such examples that require users to refresh their session to demonstrate they remain responsive.19,20
Even though virtual services may offer a viable alternative for people who are unable or unwilling to access SCS, ORHAs are still faced with barriers that hinder their utilization and uptake.13,18,21 To date, identified barriers to ORHAs include privacy concerns, fear of police arrival at their homes, not having reliable access to cell phones, and a lack of awareness of such services.18,21 While previous studies provide valuable information on the type of barriers that are present, there is currently limited research on the attitudes of ORHAs from the perspective of stakeholders in the substance use community. The current study analyzes data from the Canadian National Questionnaire on Overdose Monitoring (CNQOM), a nation-wide bilingual Canadian questionnaire that examined key stakeholder attitudes towards SCS and ORHAs. 22 To continue improving the quality of ORHAs and ensure their relevance to PWUS, it is imperative that service providers understand where barriers and limitations lie to offer safe and effective virtual monitoring. The aim of the current study is to examine perceptions of a suite of potential barriers to the use of ORHAs among key stakeholder groups.
Methods
Data source
This study reports on the data collected from the CNQOM, which was delivered digitally across Canada between July 2022 and May 2023. 22 This study presents the outcome of 13 questions specifically evaluating the barriers to ORHA which asked the respondents to rate the significance of each barrier on a Likert scale from 1 (very insignificant) to 5 (very significant). 22 The questionnaire was validated by representatives from each stakeholder group and pilot-testing was conducted by the principal investigator (SMG), the research team (NR, BS, DV, WR), healthcare providers, and people with lived experience of substance use. 22 The full details pertaining to questionnaire development, validation, and reliability assessment have been previously described. 22
Participants
Participants were recruited across Canada using a combination of purposive (via partner organizations) and representative (via a public opinion analytics firm) sampling strategies. 22 Participants had to be 18 years of age or older, reside in Canada at the time of study, and be able to understand written English or French. In addition, they had to identify with one of four key interest groups: PWUS, first responders (e.g., police, paramedic, firefighter), healthcare providers (HCP), and the general public. 22 Those who did not meet the inclusion criteria were excluded by default. Of note, participants included in this study came from one of three groups: people who are currently using substances (PWUS-C), people who used substances in the past (PWUS-P), and Addiction Service Providers (ASP). PWUS included those who use or have used illicit substances (excluding alcohol, tobacco, and cannabis). ASP included people in professions such as social work, family medicine, and nursing who identified as working in the field of addictions. An honorarium of $15.00 CAD was given to PWUS (current and past) who completed the survey using links from specific partner organizations through e-transfer or gift card. The survey was accessible to participants via Qualtrics XM platform through the University of Calgary’s subscription. Participants were offered the option to request their data to be withdrawn from analysis prior to complete de-identification (stripping of emails and IP addresses); however, no participants exercised this option.
Statistical analysis and data processing
The data was cleaned by removing all identifying information (e.g., email addresses, IP addresses, any identifying free text responses). Descriptive statistics and figures were prepared using Microsoft Excel (Microsoft Office 365) by DV. Ordinal logistic regression was conducted by BP with R 4.4.2 and SAS 9.4 software. The independent variable was the stakeholder group (ASP, PWUS-C, and PWUS). The dependent variable was the perceived significance of the barriers to accessing ORHAs. Missing data underwent casewise deletion. Percentage of deleted cases ranged from 9.3% to 11.0%.
Ethics approval and reporting
The study was approved by the University of Calgary’s Conjoint Health Research Ethics Board (CHREB; REB #21-1646). The STROBE Statement for cross-sectional studies 23 and the Checklist for Reporting Results of Internet E-Surveys (CHERRIES) were used in the drafting of this manuscript. 24
Results
Demographics
Demographic information by respondent group.
Service delivery and quality
There were a total of 6 items pertaining to service delivery and quality barriers to accessing ORHAs (Figure 1). A higher proportion of ASP (83.3%) rated concerns of police dispatch to client's home as 4 or higher on the Likert scale compared to 74.6% of PWUS-C and 73.8% of PWUS-P. Similarly, a higher proportion of ASP (76.6%) rated lack of trust in ORHAs for reducing or preventing drug poisoning/overdose risk as 4 or higher compared to 64.4% of PWUS-C and 68.6% of PWUS-P. Fear of privacy breach and information being leaked was rated as 4 or higher by 70.2% of PWUS-C, 61.9% of PWUS-P, and 74.5% of ASP. Lack of familiarity or knowledge about ORHAs was rated as 4 or higher by 65.0% of PWUS-C, 69.7% of PWUS-P, and 74. 4% of ASP. Discomfort of using ORHAs while consuming substances (i.e. handling technology in one hand while using substances in another) was rated 4 or higher by 64.4% of PWUS-C, 65.1% of PWUS-P, and 73.9% of ASP. Concerns regarding response times of EMS during a medical emergency were rated as 4 or higher by 62.6% of PWUS-C, 62.8% of PWUS-P, and 68.0% of ASP. Service delivery and quality barriers to ORHA utilization and uptake.
Technological and accessibility barriers
ASP had the highest proportion of respondents who rated lack of regular cell phone and/or phone number as 4 or higher (79.4%), followed by 72.7% of PWUS-P and 65.8% of PWUS-C (Figure 2). Lack of access to a smartphone or tablet to utilize ORHAs was rated as 4 or higher by 85.4% of ASP, compared to 65.4% of PWUS-C and 72.9% of PWUS-P. Similarly, a higher percentage of ASP (67.8%) rated inadequate battery life for the personal devices as 4 or higher in comparison to 63.3% of PWUS-C and 60.4% of PWUS-P. Technological and accessibility barriers to ORHA utilization and uptake.
Stigma and social barriers
General stigma around substance use was rated as 4 or higher by 70.5% of ASP, 62.6% of PWUS-C, and 62.4% of PWUS-P (Figure 3). Pressure to pursue recovery when using ORHAs was rated as 4 or higher by 70.1% of ASP, 60.3% of PWUS-C, and 62.0% of PWUS-P. A larger proportion of ASP (71.2%) rated potential stigma from emergency department staff as 4 or higher compared to 61.2% of PWUS-C and 59.8% of PWUS-P. Similarly, stigmatizing attitudes from EMS personnel was rated as 4 or higher by 68.6% ASP compared to to 59.3% of PWUS-C and 57.0% of PWUS-P. Stigma and social barriers to ORHA utilization and uptake.
Predicting stakeholder perception towards barriers associated with ORHA use
Service delivery and quality barriers
Ordinal logistic regression for predicting stakeholder’s perception towards barriers. The first group listed represents the numerator of odds ratio and the second group represents the denominator.
*indicates significant OR
Technological and accessibility barriers
ASP had higher odds of rating lacking a regular phone or phone number as a more significant barrier than PWUS-C and PWUS-P. Moreover, ASP had higher odds of rating lack of smart phone or tablet as a more significant barrier than PWUS-C and PWUS-P. ASP had higher odds of rating limited battery life as a more significant barrier than PWUS-P.
Stigma and social barriers
Being an ASP was associated with higher odds of rating stigma in general, stigma from emergency department staff, and stigma from EMS as a more significant barrier to ORHA than PWUS-P. No significant associations were found for pressure around pursuing recovery.
Discussion
This study using data from the CNQOM aimed to identify barriers to using ORHAs from the perspectives of people with lived experience of substance use and ASP. It complements previous qualitative studies of how uptake of ORHAs may be hindered by logistical, technological, and social barriers by offering a quantitative assessment.18,21
Our findings revealed that concerns about police dispatch to the client’s location were seen as a significant barrier across all stakeholder groups. The fear of legal consequences and police attendance at the scene have been recognized as deterrents to seeking medical help during an overdose.18,21,25 It is important to note that while some ORHAs will dispatch EMS/911 during a suspected overdose (e.g., client not responding to the operator or failing to refresh a timer), some peer-operated services like NORS will try to prioritize the client’s preferences in planning an emergency response rather than immediately resorting to EMS. 15 They achieve this by allowing clients to request that a community member, family member, or friend be the first point of contact in the event of an overdose, with first responders being a second-line option. 13 This unique service aspect of ORHAs may be something that needs to be better communicated to individuals who hesitate to seek any monitored consumption services due to fear of altercation with law enforcement. Additionally, ORHAs who do not provide this option should consider incorporating community-based responses as a part of their harm reduction platform. Likewise, potential privacy breach while using ORHAs was deemed a major barrier, echoing previous qualitative studies which have documented concerns regarding data protection and a need for clearer transparency around who has access to the data. 18 A lack of trust in the effectiveness of ORHAs and a lack of timely response were also prevalently seen as barriers to their uptake. This concern has been particularly voiced by PWUS in rural areas where EMS may not be able to arrive in time. 21 Indeed, overdose intervention (e.g., naloxone, CPR) is most effective when administered as soon as possible 26 and the virtual nature of ORHAs may fuel discomfort in its ability to reverse an overdose, particularly among people who are more familiar with on-site physical services. The discomfort associated with using ORHAs while consuming substances was additionally identified as a significant barrier. However, findings from a previous qualitative study demonstrate that PWUS may also view ORHAs as a convenient harm reduction tool as they typically operate 24/7, do not require transportation, and support routes of consumption that are generally prohibited in SCS (e.g., smoking). 27 Considering the novelty of virtual supervised consumption, it is not surprising that a general lack of awareness of ORHAs serves as a barrier to their uptake. Hence, there is a continued need to promote their awareness through effective advertising. 18 Though the current evidence is limited, the most recent data has shown promise in ORHAs for being able to avert fatal drug poisonings at least in the North American context. 28 The authors believe that they can be useful alternatives for those who are compelled to use alone. While there are studies describing the perceived safety and quantifiable benefits of these services, effectiveness data should be obtained for individual services examined.
Participants demonstrated awareness of technological and accessibility barriers to ORHAs, which parallels the recurring findings of previous studies.18,21,29 A survey of PWUS in British Columbia found that those who reported having cellphone ownership were more likely to be employed and have regular access to housing. 30 A similar study conducted in California revealed that those who were not experiencing homelessness were more likely to own a mobile phone. 31 Consequently, ORHAs may best serve a particular subgroup of PWUS, such as those who are stably housed, employed, and have the financial means to obtain reliable mobile devices.30,31 As the authors anticipate technological difficulties for certain demographics of PWUS, there is a clear need to diversify the ways in which harm reduction services are made available.
ASP found stigmatizing treatment from healthcare personnel and first responders as a profound barrier to using ORHAs. Stigma against PWUS in healthcare settings can manifest in various ways, including early discharge against medical advice/patient initiated discharges, compared to those who do not use substances.32,33 It is worth highlighting that ORHAs are often operated by peers with lived experience of substance use14,15 and this information should be emphasized to PWUS to improve acceptability of these services by alleviating concerns related to shame and stigma. 34 Indeed, many PWUS face pressure to pursue recovery or to undergo addiction treatment. 35 This can understandably create an uncomfortable and vulnerable position for clients especially if they are not ready to be at the stage of recovery. While organizations like NORS will support clients who voluntarily wish to seek rehabilitation or recovery services, 14 the operators are specifically trained not to coerce unwanted services against the client’s consent. 13
Clinical relevance of differences in barrier perception
To compare the perception between stakeholder groups, ordinal logistic regression was performed. It is important to emphasize that while the differences in perception may be statistically significant between groups, the magnitude may not be large enough to hold clinical significance, especially given the relatively large sample size. Interestingly, our study revealed that ASP were often more likely to regard the listed barriers as important compared to respondents with lived experience of substance use. Past research indicates that educational interventions can mitigate stigma against patients with substance use disorder among medical trainees.36,37 This could suggest an increased awareness of obstacles that PWUS face when it comes to seeking help during a medical emergency among those who frequently interact with this vulnerable population. Alternatively, this could indicate that ASP take on an advocacy role when asked about barriers, 38 causing them to think critically about the potential barriers and be more likely to rank the examined barriers as significant.
Strengths and limitations
One of the strengths of this nation-wide study is the large sample size of participants across all stakeholder groups. In particular, this study gave a unique focus to people with lived experience of substance use in Canada. One limitation of this study is that it is largely a descriptive analysis of the barriers to ORHA, with some inferential comparison of perception between relevant stakeholder groups. While adjusting for cofounders could provide an alternative way to explain the findings, the authors note that this is a pilot study primarily aimed at elucidating the barriers before future exploratory analysis can determine which variables are worth adjusting for. Lastly, the study included a relatively small number of ASP. Especially with ASP not receiving any compensation, this recruitment strategy may have introduced a sampling bias in which it has specifically appealed to participants with more altruistic reasons for engaging in this type of research. Future work could recruit participants specifically and solely from the client base of ORHAs to obtain more informed opinions about barriers to ORHA use rather than perceptions of potential barriers. There is also an opportunity for future studies to compare the different types of barriers between ORHAs and SCS.
Conclusion
This study highlights relevant barriers that may limit the uptake of ORHAs from the perspective of key interest groups: people with lived experience of substance use and those who work in the addiction and harm reduction field. It is one of the first attempts to quantitatively examine and compare perception of barriers between important stakeholder groups. Most barriers were perceived as significant, revealing a continued need to improve delivery of ORHAs. These findings can be used to inform organizational policies and quality improvement activities.
Supplemental material
Supplemental Material - Investigating the barriers to uptake and utilization of overdose response hotlines and apps: A study based on data from a national survey
Supplemental Material for Investigating the barriers to uptake and utilization of overdose response hotlines and apps: A study based on data from a national survey by Boogyung Seo, Nathan Rider, Dylan Viste, William Rioux, Avnit Dhanoa, Maria Vasquez, Bo Pan, Sumantra Monty Ghosh in Digital Health.
Supplemental material
Supplemental Material - Investigating the barriers to uptake and utilization of overdose response hotlines and apps: A study based on data from a national survey
Supplemental Material for Investigating the barriers to uptake and utilization of overdose response hotlines and apps: A study based on data from a national survey by Boogyung Seo, Nathan Rider, Dylan Viste, William Rioux, Avnit Dhanoa, Maria Vasquez, Bo Pan, Sumantra Monty Ghosh in Digital Health.
Footnotes
Acknowledgements
We would like to acknowledge the financial support provided by Health Canada’s Substance Use and Addictions Program (SUAP) and the Canadian Institutes of Health Research (CIHR) for this research. We also appreciate the assistance of the following entities in participant recruitment: National Overdose Response Service (NORS), Grenfell Ministries, Island Health, Doctors of Nova Scotia, Saskatchewan Medical Association, Thompson Rivers University Faculty of Social Work, College of Physiotherapists of Ontario, Safeworks, ARCH, MIELS-QUÉBEC, and CIPTO. Their contributions were instrumental in the success of this project.
Ethical considerations
The study was approved by the University of Calgary’s Conjoint Health Research Ethics Board (CHREB; REB #21-1646).
Consent to participate
Participation was voluntary and informed consent was obtained electronically.
Author contributions
All authors played crucial roles in this research. SMG took on the role of principal investigator and managed the overall project. DV was responsible for cleaning the data and provided the finalized dataset to BP, who then conducted the data analysis. The results were compiled by BS and drafted the initial manuscript, which was edited by NR, WR, AD, MV, and MG. Each author reviewed and approved the final manuscript before it was submitted.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This study received financial backing from Health Canada’s Substance Use and Addictions Program (SUAP) [Agreement No. 2122-HQ-000021] and the Canadian Institutes of Health Research (CIHR) [Funding Reference No. 181006]. SUAP and CIHR were not involved in any aspect of the study’s design, data collection, data analysis, result interpretation, or the decision to publish the findings. The opinions presented in this paper are solely those of the authors and do not necessarily represent the views of Health Canada.
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article. SMG, the co-founder of NORS, does not have any financial stakes related to this research. The outcomes of this study might influence operational modifications at NORS. The other authors have no affiliations with NORS or any other ORHAs and declare no conflicts of interest.
Data Availability Statement
The data that support the findings of this study are available from the corresponding author (SMG) on a case-by-case basis in accordance with University of Calgary policy.
Supplemental material
Supplemental material for this article is available online.