Little is known about differences in bystander behavior among people who use drugs, trained and untrained in opioid overdose prevention. We examined three types of recommended overdose response - a 911 call, rescue breathing/CPR, and naloxone administration-among Philadelphia-based, predominantly street-involved women with a history of illicit drug use. The study utilized a convergent mixed methods approach integrating data from 186 quantitative survey responses and 38 semi-structured qualitative interviews. Quantitative findings revealed that compared to untrained women, trained women were more likely to administer naloxone (32.9% vs. 5.2%) and use two recommended responses (20.0% vs. 9.5%). No significant differences were found between the two groups in calling 911 or using rescue breathing/CPR. Qualitative findings indicated that barriers to enacting recommended overdose response were either structural or situational and included the avoidance of police, inability to carry naloxone or phone due to unstable housing, and perceived lack of safety on the streets and when interacting with strangers. Our study demonstrated that overdose training improved the frequency of naloxone administration among this sample of predominantly street-involved women. Future efforts need to focus on avoiding intrusive policing, scaling-up naloxone refill sites, and providing secondary naloxone distribution via drug user networks.
Keywords: 911 call; naloxone; opioid overdose; overdose prevention training; rescue breathing; street involvement; women.