Circumstances of witnessed drug overdose in New York City: implications for intervention.

Abstract

Drug users frequently witness the nonfatal and fatal drug overdoses of their peers, but often fail to intervene effectively to reduce morbidity and mortality. We assessed the circumstances of witnessed heroin-related overdoses in New York City (NYC) among a predominantly minority population of drug users. Among 1184 heroin, crack, and cocaine users interviewed between November 2001 and February 2004, 672 (56.8%) had witnessed at least one nonfatal or fatal heroin-related overdose. Of those, 444 (67.7%) reported that they or someone else present called for medical help for the overdose victim at the last witnessed overdose. In multivariable models, the respondent never having had an overdose her/himself and the witnessed overdose occurring in a public place were associated with the likelihood of calling for medical help. Fear of police response was the most commonly cited reason for not calling or delaying before calling for help (52.2%). Attempts to revive the overdose victim through physical stimulation (e.g., applying ice, causing pain) were reported by 59.7% of respondents, while first aid measures were attempted in only 11.9% of events. Efforts to equip drug users to manage overdoses effectively, including training in first aid and the provision of naloxone, and the reduction of police involvement at overdose events may have a substantial impact on overdose-related morbidity and mortality.

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Drug and Alcohol Dependence 79 (2005) 181–190
Circumstances of witnessed drug overdose in New York City:
implications for intervention
Melissa Tracya, Tinka Markham Pipera, Danielle Ompada, Angela Bucciarellia,
Phillip O. Coffina, David Vlahova,b, Sandro Galeaa,b,∗
aCenter for Urban Epidemiologic Studies, New York Academy of Medicine, 1216 Fifth Avenue, New York, NY 10029, USA
bDepartment of Epidemiology, Columbia University Mailman School of Public Health, New York, NY 10032, USA
Received 31 August 2004; received in revised form 7 January 2005; accepted 26 January 2005
Abstract
Drug users frequently witness the nonfatal and fatal drug overdoses of their peers, but often fail to intervene effectively to reduce morbidity
andmortality.Weassessedthecircumstancesofwitnessedheroin-relatedoverdosesinNewYorkCity(NYC)amongapredominantlyminority
populationofdrugusers.Among1184heroin,crack,andcocaineusersinterviewedbetweenNovember2001andFebruary2004,672(56.8%)
had witnessed at least one nonfatal or fatal heroin-related overdose. Of those, 444 (67.7%) reported that they or someone else present called
for medical help for the overdose victim at the last witnessed overdose. In multivariable models, the respondent never having had an overdose
her/himself and the witnessed overdose occurring in a public place were associated with the likelihood of calling for medical help. Fear of
policeresponsewasthemostcommonlycitedreasonfornotcallingordelayingbeforecallingforhelp(52.2%).Attemptstorevivetheoverdose
victim through physical stimulation (e.g., applying ice, causing pain) were reported by 59.7% of respondents, while first aid measures were
attempted in only 11.9% of events. Efforts to equip drug users to manage overdoses effectively, including training in first aid and the provision
of naloxone, and the reduction of police involvement at overdose events may have a substantial impact on overdose-related morbidity and
mortality.
© 2005 Elsevier Ireland Ltd. All rights reserved.
Keywords: Overdose; Heroin; Drug use; Emergency medical services
1. Introduction
Approximately half of all illicit drug users report at least
one nonfatal overdose during their lifetime (Seal et al., 2001;
Ochoa et al., 2001; Davidson et al., 2002), and death rates
fromaccidentaldrugoverdosehavebeenincreasingthrough-
out the United States over the past decade (CDC, 2000a,
2000b, 2004). In New York City (NYC), deaths due to drug
abuse currently rank among the five leading causes of death
in 15–54 year olds (NYC DOHMH, 2003), and drug-related
hospitalizationaccountedforupto9.0%ofallhospitaladmis-
sions in 2001 in some neighborhoods (Karpati et al., 2003a,
2003b). Complications of drug overdose include pulmonary
edema, cardiac arrhythmia, rhabdomyolysis, cognitive im-
∗Corresponding author. Tel.: +1 212 822 7378; fax: +1 212 876 6220.
E-mail address: sgalea@nyam.org (S. Galea).
pairment, and indirect physical injury resulting from unin-
tentional falls and burns (Sporer, 1999; Darke et al., 2000;
Warner-Smith et al., 2001, 2002).
Drug users rarely overdose while alone (Darke and Hall,
2003; Sergeev et al., 2003; Powis et al., 1999; Darke et al.,
1996a),anddeathfromdrugoverdoseisrarelyinstantaneous
(Zador et al., 1996; Darke and Zador, 1996), creating op-
portunities for those present to reduce potential morbidity
and mortality through timely intervention. More than 90%
of heroin overdose victims who receive emergency medical
care while still exhibiting pulse and blood pressure survive
(Sporer et al., 1996), although neurological and other phys-
ical effects of overdose become more severe if hypoxia is
prolonged (Darke et al., 1996b, 2000; Warner-Smith et al.,
2001) affirming the importance of seeking medical attention
as quickly as possible during overdose events. It has been es-
timated that only between 10% and 56% of individuals who
0376-8716/$ – see front matter © 2005 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.drugalcdep.2005.01.010

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witnessadrugoverdosecallforemergencymedicalservices,
with most of those doing so only after other attempts to re-
vivetheoverdosevictim(e.g.,inflictingpainorapplyingice)
haveprovedunsuccessful(Davidsonetal.,2002;Zadoretal.,
1996; Darke et al., 1996b; McGregor et al., 1998). Few stud-
ies have assessed responses to witnessed overdoses among
minority populations, although these populations suffer dis-
proportionately from the consequences of drug use in many
cities (Galea et al., 2003a; Davidson et al., 2003; Galea and
Vlahov,2002).Also,differencesinseekinghelpforoverdose
victims may exist between racial/ethnic groups (Davidson
et al., 2002; Galea et al., 2003a). Understanding the factors
associatedwithappropriateresponsesduringwitnessedover-
dose events among minority populations may help to elimi-
nate barriers to obtaining emergency medical care for over-
dosevictimsandreduceoverdose-relatedmorbidityandmor-
tality (Darke and Hall, 2003; Davidson et al., 2002; Ochoa
et al., 2001; Darke et al., 1996b).
We assessed the circumstances of witnessed nonfatal and
fatal heroin-related overdoses in NYC to determine the re-
sponsestooverdosecommonamongapredominantlyminor-
ity urban population of illicit drug users. We sought to iden-
tify predictors of and barriers to seeking medical help during
witnessed overdose events, in order to inform interventions
aimed at reducing the consequences of drug overdose.
2. Methods
2.1. Participants and measures
Recruitment, involving targeted sampling with street out-
reach techniques, was carried out by trained outreach work-
ers in Central Harlem and the South Bronx in NYC from
November 2001 through February 2004. Recruitment meth-
ods used in this study have been described in more detail
elsewhere (Diaz et al., 2001a, 2001b; Ompad et al., in press).
Eligibility requirements included being 18 years of age or
older and having used heroin, crack, or cocaine at least once
in the 2 months prior to the interview. Questionnaires were
administered in English or Spanish by trained interviewers,
assessing demographic characteristics, drug use behaviors,
and overdose experience.
“Overdose” was defined as “someone who collapses, has
blue skin color, convulsions, difficulty breathing, loses con-
sciousness, cannot be woken up, or has a heart attack or dies
while using drugs.” We asked respondents if they had ever
overdosed; those who had were asked how many times they
had overdosed in the past 6 months, in the past year, and in
theirlifetime.Theywerealsoaskedtoprovidedetailedinfor-
mation about their most recent overdose experience, includ-
ingthedrugstheywereusing,whetherotherswerepresent,if
they received any medical attention, and if they had recently
beeninprisonordrugtreatmentbeforetheoverdose.Wealso
asked participants if they had ever seen someone else over-
dose; those who had were asked how many times they had
seen an overdose in the past 6 months and in their lifetime.
They were also asked to describe the circumstances of the
overdose they had seen most recently, including their rela-
tionship to the person who overdosed, the drugs that person
was using at the time of the overdose, and if the person lived
or died. This analysis is limited to witnessed overdose events
in which heroin was reported to have been used, either alone
orincombinationwithotherdrugs,inordertofacilitatecom-
parisonswithotherstudies.Inaddition,witnesseswereasked
iftheyoranyoneelsepresenthadsoughtoutsidemedicalhelp
for the overdose victim and were subsequently asked to enu-
merate the actions taken during the overdose event. Partici-
pantswhoresponded“yes”tothequestion“didyouorothers
there get or call for outside medical help?” or who reported
thatsomeonepresentcalledanambulance,tooktheoverdose
victimtothehospital,orwentforhelpfromothersduringthe
last witnessed overdose were considered to have “called for
medical help” in the following analysis. Respondents who
had ever seen someone overdose were also asked if they had
hesitated before getting or calling for medical help at the last
witnessed event; those who reported delaying or not calling
for help were asked to list the reasons why they had delayed
orfailedtogethelp.Finally,weaskedrespondentsiftheyhad
ever personally known anyone who died of a drug overdose.
2.2. Analyses
We calculated the prevalence of ever witnessing a nonfa-
tal or fatal drug overdose and, restricting the sample to re-
spondents whose most recently witnessed overdose involved
heroin, we described the demographic and drug use charac-
teristics of the witnesses as well as circumstances of the last
heroin-related witnessed overdose event. We used two-tailed
χ2-tests to assess the relations between characteristics of the
witness and of the witnessed overdose event and the likeli-
hood that those present called for medical help for the over-
dose victim. All characteristics that were associated (p<0.2)
with calling for medical help at the last witnessed overdose
were included in a multivariable model. We also restricted
the sample to witnesses who had ever overdosed themselves
and created a second multivariable model in order to assess
the specific characteristics of one’s prior overdose history
that may influence responses to witnessed overdose. Finally,
we described the actions taken by those present at the last
heroin-related witnessed overdose and the reasons reported
for delaying or not getting help.
3. Results
3.1. Prevalence of witnessed overdose
Of 1184 participants recruited to the study, 797 (67.3%)
reported ever having witnessed a nonfatal or fatal drug over-
dose. Of these, 278 (35.2%) had seen an overdose in the past
6 months. The median number of overdoses witnessed dur-

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M. Tracy et al. / Drug and Alcohol Dependence 79 (2005) 181–190
183
ing respondents’ lifetime was five, while the mean number
of overdoses witnessed was 11.8. Respondents who had seen
an overdose were more likely than those who had never seen
an overdose to have ever been in jail (86.9% versus 78.5%;
p<0.001), to be current injectors (61.7% versus 50.0%;
p<0.001),tohaveeverbeenindrugtreatment(92.5%versus
85.0%; p<0.001), and to have ever overdosed (44.7% ver-
sus 19.4%; p<0.001). Of the 797 respondents who had ever
seensomeoneelseoverdose,672(84.3%)reportedthatheroin
was being used by the overdose victim at the most recently
witnessed overdose event. An average of 4.3 years (S.D. 7.2
years;median1year;range<1–44years)hadpassedbetween
thelastwitnessedoverdoseandtheinterviewamongthesere-
spondents. The most recently witnessed heroin-related over-
dose reportedly ended in death in 132 (21.2%) cases.
3.2. Characteristics of witnesses and last witnessed
overdose
Table 1 summarizes the demographic characteristics and
overdose experience of respondents who had witnessed a
heroin-related overdose, as well as the circumstances of the
last witnessed overdose. The majority of witnesses had in-
jected drugs in the previous 2 months (64.3%) and had been
using drugs for over 20 years (52.7%) at the time of the in-
terview. About a quarter (25.7%) of the witnesses had seen
morethan10overdosesintheirlifetimeand302(45.0%)had
ever experienced a nonfatal drug overdose themselves. Over
half (56.8%) of those who had overdosed had been taken to
the hospital during their last overdose. A plurality of wit-
nessed overdoses took place in residential settings (35.8%),
25.0% occurred in public areas like bars, restaurants, and on
thestreet,and19.2%ofeventsoccurredinshootinggalleries.
In addition to heroin, cocaine or crack was reportedly being
usedbytheoverdosevictimin34.7%ofevents,whilealcohol
was used in 7.5% of events.
3.3. Predictors of calling for help at last witnessed
overdose
During the most recently witnessed heroin-related over-
dose,444(67.7%)respondentsreportedthattheyorsomeone
else present called for medical help for the overdose victim.
Table 1 shows the bivariate associations between character-
istics of the witness and of the witnessed event and the like-
lihood that someone present called for medical help for the
overdose victim. Covariates associated with whether some-
onepresenthadcalledforhelpduringthelastwitnessedover-
dose event were the respondent’s history of methadone treat-
ment (p=0.03) and the location of the witnessed overdose
event (p<0.001). Additionally, respondents who had ever
overdosedthemselveswerelesslikelytocallformedicalhelp
than those with no history of prior overdose (59.1% versus
74.9%;p<0.001);however,amongthosewhohadoverdosed
themselves, those who had been taken to the hospital at their
ownlastoverdoseweremorelikelytocallforhelpduringthe
last witnessed overdose than those who had not been taken
to the hospital (72.6% versus 41.9%; p<0.001). Among wit-
nessed events at which medical help was called, witnesses to
incidentsoccurringinpublicplacesweremorelikelytoreport
being of no relation to the victim than in incidents occurring
in other private locations (41.2% versus 16.5%; p<0.001;
data not shown).
Table 2 shows the unadjusted and adjusted relations be-
tween characteristics of the witness and of the witnessed
overdose event and the likelihood that those present called
for medical help for the overdose victim. In the first ad-
justed model, which includes all respondents who had most
recentlywitnessedaheroin-relatedoverdose(N=652),med-
ical help was more likely to have been called for the over-
dose victim if the overdose occurred in a public place
(OR=2.20versusoverdosesoccurringinresidentialsettings;
95% CI=1.35–3.58) but was less likely to have been called
iftherespondenthadeveroverdosed(OR=0.56versusnever
overdosed; 95% CI=0.39–0.80), after controlling for other
characteristics of the witness and of the witnessed overdose
event.Inthesecondmultivariablemodel,whichincludesonly
those witnesses to heroin-related overdoses who had ever
overdosed themselves (N=291), the only significant predic-
tor of calling for medical help was having been taken to the
hospital during one’s own last overdose (OR=3.18 versus
having not been taken to the hospital; 95% CI=1.44–6.99).
3.4. Actions taken at last witnessed overdose
Table3liststheactionsthatwitnessesreportedweretaken
by those present during the most recently witnessed over-
dose. Overall, an ambulance was called in 40.0% of wit-
nessedoverdoseevents,whileattemptstorevivetheoverdose
victim through physical stimulation, including applying ice
and causing pain, were made in 59.7% of incidents. First
aid measures, such as cardiopulmonary resuscitation (CPR)
and placing the overdose victim in the coma position, were
attempted in only 11.9% of cases, while those present left
or did nothing for the overdose victim in 14.1% of events.
Witnesses who did not call for medical help for the over-
dose victim were more likely than those who did call for
help to attempt to stimulate the victim by applying ice, walk-
ing the victim around, injecting the victim with water, salt,
or bleach, or causing pain (79.3% versus 50.5%; p<0.001),
and were less likely to attempt first aid (7.6% versus 14.4%;
p=0.012).
3.5. Reasons for not calling or delaying before calling
for help at last witnessed overdose
Table 4 shows the reasons reported by witnesses for not
seeking or delaying before seeking medical help during the
last witnessed overdose. The most commonly cited reason
for delaying or failing to get help was fear of police response
(52.2%).Amongthosewhocalledformedicalhelpatthelast
witnessed overdose, 21.2% delayed before calling for help;

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Table 1
Bivariate associations between characteristics of witnesses and of witnessed heroin-related overdose events and the likelihood that someone present called for
medical help during the last witnessed overdose
TotalCalled for medical help for victim
N
%
N called% called
p-value
Total witnesses to overdose672 100.0 44467.7
Demographic characteristics of witnesses
Age
18–24
25–34
35–44
45–54
55–64
416.1
29.5
41.1
21.4
1.9
2460.0
70.3
69.0
64.3
61.5
0.58
198
276
144
13
137
185
90
8
Gender
Female
Male
157
511
23.5
76.5
108
333
70.6
66.7
0.37
Race/ethnicity
White or other race
Black
Hispanic
88
167
417
13.1
24.9
62.1
5663.6
66.7
69.0
0.60
106
282
Educational attainment
<High school
High school/equivalent or higher
322
347
48.1
51.9
223
219
70.6
65.0
0.13
Marital status
Never married
Married
Separated/widowed/divorced
402
95
174
59.9
14.2
25.9
276
63
105
69.9
69.2
62.1
0.19
Ever homeless
No
Yes
8612.8
87.2
5665.1
68.1
0.59
586 388
Ever arrested
No
Yes
517.6
92.4
3571.4
67.4
0.56
621409
Ever in jail
No
Yes
7611.9
88.1
5068.5
67.0
0.80
564370
Injector status
Never
Former
Current
81 12.2
23.5
64.3
6277.5
70.1
64.6
0.06
156
427
103
272
Length of drug-using career
<1–10 years
11–15 years
16–20 years
21+ years
72
99
10.8
14.8
21.8
52.7
48
72
94
67.6
72.7
65.3
67.3
0.67
146
353 230
Ever in methadone treatment
No
Yes
203
469
30.2
69.8
145
299
73.6
65.1
0.03
Ever in detox or other type of drug treatment
No
Yes
114
558
17.0
83.0
74 66.7
67.9
0.80
370
Any risky injection practices at last injectiona
No
Yes
278
247
53.0
47.1
183
152
66.6
64.1
0.57
Characteristics of witnessed overdose events
Relationship of overdose victim to witness
No relation 16725.0 10668.40.97

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M. Tracy et al. / Drug and Alcohol Dependence 79 (2005) 181–190
185
Table 1 (Continued)
Total Called for medical help for victim
N
%
N called% called
p-value
Fellow drug user
Friend/family member/sexual partner
558.2
66.8
36 66.7
67.9 447 302
Location of witnessed overdose
Home
Shooting gallery
Abandoned building/SRO/hotel room
Public placeb
Otherc
239
128
51
167
82
35.8
19.2
7.7
25.0
12.3
150
75
28
131
56
63.8
61.5
57.1
79.9
68.3
< 0.001
OD victim was using cocaine or crack
No
Yes
439
233
65.3
34.7
292
152
68.2
66.7
0.68
OD victim was using alcohol
No
Yes
614
50
92.5
7.5
409
30
68.1
62.5
0.43
OD victim was using tranquilizers/barbs/benzos
No
Yes
643
21
96.8
3.2
424
15
67.5
71.4
0.71
OD victim was using other drug(s)
No
Yes
583
89
86.8
13.2
386
58
68.0
65.9
0.70
OD victim was using more than one drug
No
Yes
388
284
57.7
42.3
254
190
67.2
68.4
0.76
Overdose experience of witnesses
Number of overdoses witnessed in lifetime
1–2
3–5
6–10
11+
181
174
144
173
26.9
25.9
21.4
25.7
128
120
93
103
72.7
70.2
66.0
61.3
0.12
Ever personally known anyone who died of an OD
No
Yes
187
470
28.5
71.5
127
305
69.8
66.2
0.38
Ever overdosed
No
Yes
369
302
55.0
45.0
269
175
74.9
59.1
< 0.001
Someone called 911 at own last OD
No
Yes
146
152
49.0
51.0
64 45.4
71.5
< 0.001
108
Taken to hospital at own last OD
No
Yes
131
172
43.2
56.8
54 41.9
72.6
< 0.001
122
aRisky injection practices include splitting drug with needle and sharing cooker, cotton, rinse water, or needle.
bPublic place includes street, schoolyard, parking lot or other open area, bar, restaurant, store or other public building.
cOther location includes car, jail, or “other”.
the most frequently reported reason for the delay was fear
of police response (66.3%). Among those who did not call
for medical help, 46.2% reported fear of police response as
a reason for not getting help, while 36.3% did not get help
because they thought they could handle the overdose event
themselves.Ofthosewhocitedabeliefintheirabilitytohan-
dletheeventwithoutaidasareasonfornotgettinghelp,only
1(1.3%)reportedafataloutcomeforthewitnessedoverdose,
significantly less than the 11.3% of outcomes reported to be
fatal by respondents who did not call for help due to other
reasons (p=0.009; data not shown).
4. Discussion
In a study of 1184 drug users, we found that a substantial
proportion had witnessed at least one overdose in their life-
time, with the majority of most recently witnessed incidents

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M. Tracy et al. / Drug and Alcohol Dependence 79 (2005) 181–190
Table 2
Unadjusted and adjusted relations between characteristics of witnesses and of witnessed heroin-related overdose events and the likelihood that someone present
called for medical help during the last witnessed overdose
Unadjusted
(N=672)
OR
Adjusted Model I including
all witnesses (N=652)†
OR95% CI
Adjusted Model II including witnesses
who ever overdosed (N=291)a
OR 95% CI95% CI
Demographic characteristics of witnesses
Educational attainment
<High school
High school/equivalent or higher
1.00
0.77
–
0.56–1.08
1.00
0.93
–
0.66–1.32
1.00
0.93
-
0.55-1.58
Marital status
Never married
Married
Separated/widowed/divorced
1.00
0.98
0.71
–
0.60–1.60
0.49–1.04
1.00
1.00
0.71
–
0.60–1.68
0.48–1.06
1.00
0.90
0.92
-
0.42-1.93
0.50-1.69
Injector status
Never
Former
Current
1.00
0.65
0.50
–
0.35–1.20
0.29–0.87
1.00
0.80
0.69
–
0.42–1.53
0.38–1.25
1.00
0.60
0.72
–
0.16-2.22
0.21–2.50
Ever in methadone treatment
No
Yes
1.00
0.78
–
0.56–1.09
1.00
0.74
–
0.50–1.11
1.00
0.58
–
0.31–1.09
Characteristics of witnessed overdose events
Location of witnessed overdose
Home
Shooting gallery
Abandoned building/SRO/hotel room
Public placeb
Otherc
1.00
0.88
0.74
2.19
1.19
–
0.56–1.38
0.39–1.37
1.38–3.49
0.70–2.03
1.00
0.93
0.79
2.20
1.19
–
0.58–1.50
0.41–1.51
1.35–3.58
0.68–2.07
1.00
0.75
0.52
1.31
1.00
–
0.37–1.53
0.21–1.32
0.64–2.68
0.44–2.29
Overdose experience of witnesses
Number of overdoses witnessed in lifetime
1–2
3–5
6–10
11+
1.00
0.88
0.73
0.59
–
0.55–1.41
0.45–1.18
0.38–0.94
1.00
1.06
0.74
0.68
–
0.65–1.73
0.44–1.23
0.42–1.11
1.00
1.67
1.06
0.78
–
0.78–3.58
0.48–2.30
0.37–1.64
Ever overdosed
No
Yes
1.00
0.48
–
0.35–0.68
1.00
0.56
–
0.39–0.80
Someone called 911 at own last overdose
No
Yes
1.00
3.02
–
1.86-4.91
1.00
1.26
–
0.57–2.75
Taken to hospital at own last overdose
No
Yes
1.00
3.68
–
2.26–6.00
1.00
3.18
–
1.44-6.99
aModel includes all witnesses to overdose who had ever overdosed themselves and who had non-missing values for all covariates (N=291).
bPublic place includes street, schoolyard, parking lot or other open area, bar, restaurant, store or other public building.
cOther location includes car, jail, or “other”.
†Model includes all respondents who had ever witnessed an overdose and who had non-missing values for all covariates (N=652).
involving heroin. About one third of witnesses to heroin-
related overdose did not get medical help for the victim dur-
ing the last witnessed overdose event, citing fear of police
responseasthemostcommonconcern.Therespondentnever
having had an overdose her/himself and the witnessed over-
doseoccurringinapublicplacewereassociatedwiththelike-
lihood of calling for medical help during the last witnessed
overdose. Only a small proportion of respondents engaged in
first aid attempts, while physical stimulation attempts were
common.
The high proportion of respondents in this study who
had ever witnessed a heroin-related overdose is consis-
tent with findings in several other studies (Darke and
Hall, 2003; Davidson et al., 2002; Darke et al., 1996b;
Strang et al., 1999), suggesting that habitual drug users
will likely be confronted with the opportunity to help
an overdose victim at some point in their drug using
career. The prevalence of calling for medical help in
this study was also comparable, if slightly higher, than
that reported in other locations (Davidson et al., 2002;

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187
Table 3
Actions taken at last heroin-related witnessed overdose
*Two-tailed χ2p-value<0.05 for relation between calling for medical help for the overdose victim and each of the possible actions taken.
McGregor et al., 1998; Darke et al., 1996b; Bennett and
Higgins, 1999).
Witnesses to overdose events occurring in public areas
like bars, restaurants, and on the street were more likely
to get medical help for the overdose victim than witnesses
to overdoses occurring in residential settings. A larger per-
centage of witnesses to overdoses occurring in public lo-
cations reported being of no relation to the overdose vic-
tim; it may be possible that unconnected bystanders and
even family members and friends may be more likely to
call for help in public situations, as such situations afford
greater anonymity and, consequently, less fear of personal
trouble arising from potential police response. However, re-
search in the United States and elsewhere has indicated
that the majority of fatal overdoses occur in private loca-
tions like homes and hotels (CDC, 2000a; Davidson et al.,
2003; Sporer, 2003), as concerns about police surveillance
often prompt drug users to engage in drug-related activi-
ties in less visible areas (Dovey et al., 2001; Burris et al.,
2004); accordingly, harm reduction efforts need to work to
improve responses to overdoses occurring in private loca-
tions.
Respondentswithapersonalhistoryofoverdosewereless
likely to seek outside help during the last witnessed overdose
than those lacking such experience. This may reflect a belief
on the part of witnesses who have overdosed themselves that
they are equipped to handle the situation without aid, having
experienced a similar incident personally. Since greater fre-
quency of alcohol use and drug injection is associated with
prior overdose experience (Seal et al., 2001; Bennett and
Higgins, 1999; Powis et al., 1999; McGregor et al., 1998;
Darke et al., 1996a), it is also possible that respondents with
ahistoryofoverdoseweremorelikelytobeintoxicatedwhen
theywitnessedanoverdose,hencehavingimpairedjudgment
and being less likely to call for medical help. However, re-
spondentswhohadbeentakentothehospitalduringtheirown
mostrecentoverdoseweremorelikelytocallforoutsidehelp
than those who had not received such medical attention. It is
possible that uncertainties and fears about medical care and
potential police involvement at overdose events, which com-
monly dissuade drug users from seeking help (Sergeev et al.,
2003; Davidson et al., 2002), were less acute among those
who had already experienced an overdose and subsequent
hospitalization themselves.

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M. Tracy et al. / Drug and Alcohol Dependence 79 (2005) 181–190
Table 4
Reasons for delaying before calling or not calling for medical help at last heroin-related witnessed overdose
Attempts to revive overdose victims through physical
stimulation(e.g.,applyingice,causingpain)werecommonly
reported among witnesses, as has been documented in other
studies (Davidson et al., 2002; Bennett and Higgins, 1999).
A greater percentage of respondents in this study (19.3%)
engaged in the ineffective practice of injecting the overdose
victim with water, salt, bleach, or speed than has been pre-
viously reported by young injection drug users in San Fran-
cisco(2%;Davidsonetal.,2002),whileasmallerpercentage
(11.9%) employed first aid measures than has been reported
by witnesses to overdose in San Francisco (57.0%; Davidson
et al., 2002), Australia (39.0%; McGregor et al., 1998), and
the United Kingdom (45.0%; Bennett and Higgins, 1999).
These discrepancies may be attributed to differential knowl-
edge of and experience in overdose prevention and treatment
amongdrugusingpopulationsindifferentlocations.Thehigh
prevalence of ineffective methods in treating witnessed over-
doses suggests that more education in appropriate overdose
management is needed among drug users, including train-
ing in first aid, especially in light of research indicating that
bystander CPR performed prior to the arrival of emergency
medical services improves outcomes for overdose victims
(Dietze et al., 2002).
Mortality as a result of heroin overdose was significantly
lesslikelyduringoverdoseeventsinwhichwitnessesthought
theywerecapableoftakingcareoftheoverdosevictimwith-
out aid. This finding may indicate that drug users who have
been adequately trained in overdose management techniques
andwhofeelconfidentintheirabilitiestopracticethosetech-
niquesmaybeeffectiveinpreventingoverdosemortality,pro-
viding further evidence in favor of increased efforts to train
drug users in first aid and other skills. However, these results
shouldbeinterpretedwithcautioninlightofthesmallsample
from which they were derived.
Fear of police response, including concerns over out-
standing warrants and potential manslaughter charges, dom-
inated the reasons reported by witnesses for not getting or
delaying before getting help for the overdose victim, as
has been reported elsewhere (McGregor et al., 1998; Darke
et al., 1996b). Police attendance at overdose events has var-
ied from 13–16% of nonfatal overdoses in Australia (Dietze
et al., 2003; Clark and Bates, 2003) to 95% of fatal over-
doses in San Francisco (Davidson et al., 2003), with 5%
of witnesses to overdoses in San Francisco reporting hav-
ing been arrested at least once while present at an overdose
event(Davidsonetal.,2002).Whilewedonothavecompara-
bledataforoverdoseeventsoccurringinNYC,itseemsclear
that drug users perceive a high risk of arrest associated with
calling for emergency medical services after an overdose in
NYC.

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M. Tracy et al. / Drug and Alcohol Dependence 79 (2005) 181–190
189
Therewereanumberoflimitationstothisstudy.Wedonot
knowiftherespondentorsomeoneelsepresentperformedthe
actions reported at the last witnessed overdose, reducing our
power to detect associations between characteristics of the
witness and the likelihood of calling for medical help during
observed overdose events. Additionally, the cross-sectional
nature of the study presents some difficulties in assessing the
time frame of the respondent’s own overdose experience in
relation to the witnessed overdose event. Since all informa-
tionpresentedherewasobtainedviaself-report,itispossible
that respondents did not have complete information about
the results of the overdoses they witnessed or were not fully
aware of the actions taken at their own most recent overdose
because of impaired consciousness at the time. Furthermore,
the variation in amount of time elapsed between the last wit-
nessedoverdoseandtheinterviewmayhaveledtodifferential
memory and reporting of actions and outcomes. In addition,
our ability to compare the responses to witnessed overdose
across drug users of different races/ethnicities was limited
by our predominantly minority sample, and thus relatively
small comparison group of white drug users. Finally, since
participants were drawn from select neighborhoods in NYC
with high proportions of minority populations, results may
not be generalizable to other populations or cities.
Despite these limitations, our findings lend further sup-
port to the notion that drug users are frequently confronted
with opportunities to reduce morbidity and mortality from
overdose in their peers, but often do not act effectively. Drug
users should be encouraged to activate the emergency med-
ical system immediately when witnessing an overdose and
police involvement at the scene of drug overdoses should
be reduced. Injection drug users have expressed a willing-
ness to participate in programs providing training in CPR as
well as take-home naloxone and instruction in its use (Seal
et al., 2003); such interventions may be particularly effective
among members of large injection drug networks (Latkin
et al., 2004) and should be considered in NYC. Harm reduc-
tion activities that provide education about overdose preven-
tion and equip drug users to manage overdoses successfully
oncetheyoccur,aswellaseffortstoimprovesocialandstruc-
tural conditions that contribute to increased risk for overdose
among drug users (e.g., homelessness and income distribu-
tion),canmakeasubstantialdifferenceinoverdosefrequency
and outcomes (Darke and Hall, 2003; McGregor et al., 1998;
Strang et al., 1999; Fischer et al., 2004; Galea et al., 2003b).
The circumstances of witnessed overdoses should be further
described in other populations and cities to more fully assess
differences in responses that may be associated with differ-
ential morbidity and mortality by race/ethnicity.
Acknowledgements
This work was funded by grants DA-06534, DA-12801-
S1, and R01-DA-017642-01 from the National Institutes of
Health.
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