1. Introduction
Since 2010, the rise in opioid overdose mortality among Black individuals has outpaced that of their non-Hispanic White counterparts.Reference Friedman, Beletsky and Jordan1 These disparate trends in mortality reflect the presence of structural racism in addiction treatment and policy and demonstrate the importance of public health interventions that take it into account.Reference Kunins2 To explore this trend, we combine our study of 50 interviews with Black residents of Indianapolis, Indiana with an examination of the policies that impact the environment in which they may witness an overdose. Participant narratives frame our policy analysis by providing insight into why Black residents may or may not call 911 after an overdose event. We explore how current policies around overdose response contribute to participant perceptions by affecting the environment in which overdose occurs, and how policies can be amended to create an environment in which witnesses feel more willing to call 911. We consider the health behavior of calling 911 due to its utility in bringing medical professionals to an overdose event and inclusion in layperson response curricula. Our findings provide insight into the intention to call 911 and how that intention is impacted by negative experiences with and perceptions of law enforcement. Policy change is one factor among many that can increase intention to call 911. Under Indiana’s overdose Good Samaritan laws (GSLs), an individual administering naloxone (e.g., Narcan) to a person who has overdosed may be protected from criminal and civil liability. GSLs can reduce consequences related to calling 911 and law enforcement arriving at an overdose event, but in Indiana and many other states, their protections are contingent on a caller meeting several conditions. We examine the role of GSLs in harm reduction and in perpetuating structural racism and explore how all of this is borne out in the lives of Black people impacted by the opioid epidemic in Indiana. We assert that the conditions in Indiana’s GSL render its ability to create a protective and intervention-focused environment ineffective in cases wherein the conditions are not adequately met, thereby perpetuating race-based disparities in overdose outcomes. Finally, we provide recommendations for making GSLs more protective, creating an environment in which beneficial encounters with law enforcement are more likely to occur, with the aims of increasing individual perceptions that calling 911 can be more helpful than harmful after an overdose and increasing intentions to engage in that behavior both in Indiana and nationally.
The opioid epidemic claimed 2,682 lives in Indiana3 in 2022, 852 of whom were in Marion County,4 where Indianapolis is located. While overdose mortality nationwide stagnated from 2021 to 2022 and decreased from 2022 to 2023, Black communities experienced a statistically significant increase in both years.Reference Spencer, Garnett and Miniño5 Through interviews with 50 Black residents of four Indianapolis zip codes, we gain insight into reasons why this may be occurring. With particular interest in health behaviors that bring first responders to the scene, we use the Health Belief Model to analyze the interviews and gain understanding regarding beliefs that may impact participants’ intention to call 911 after an overdose. Slow response after a call, lack of care at the scene, and fear of experiencing criminalization and/or police brutality were some of the most salient factors that impacted participants’ beliefs about the benefits of and the barriers to calling 911. Interestingly, we observed that experiencing or witnessing a helpful police interaction improved the perception that calling 911 to an overdose could be beneficial, even when participants were still concerned with barriers like criminalization and/or police brutality. We surmise that witnessing helpful encounters with police can increase the intention to call 911 when an overdose occurs, despite existing fear and mistrust in law enforcement overall. When considering ways to increase the chances that police response to an overdose will result in a helpful encounter, we look to how policies around substance use influence the environment in which laypeople choose to respond. Because substance use-related GSLs deal specifically with overdose response, we identified these as key policy factors in fostering an environment in which people may feel better able to call for help.
Passed in 2015 and amended in 2016, Indiana’s GSL, also known as Aaron’s Law, was created to encourage laypeople to carry and administer naloxone if they witness an overdose and to call first responders for help.6 This policy has been protective; however, it does not fully address barriers to administering naloxone and calling 911 within the Black community, such as fear and mistrust of police.Reference Seo7 This example highlights how harm reduction policies can perpetuate racial disparities in health outcomes among people who use drugs. Policies like Aaron’s Law’s current iteration, that limit who is protected and lean on police discretion, can disadvantage Black communities, whose residents are less likely to be covered by the GSL. In the following analysis, we find that witnessing police brutality or perceiving it as a likely outcome of police interaction may negatively impact intent to call 911 for help, while witnessing a helpful and positive police interaction can increase the perceived benefits of calling 911 after an overdose. These findings can help attorneys, public health professionals, and advocates understand how systemic racism in drug policy, even in harm reduction policies, can result in disparate health outcomes in Black communities, and how strategic changes can improve those outcomes. We draw a connection from policy and law to the environment and context where an overdose occurs, and then to individual health behaviors. We conclude with policy recommendations that increase the protections afforded by Aaron’s Law in light of the “racialization and hypercriminalization of Black people”Reference Lopez8 within drug policies and the criminal justice system.
2. Contextual and Legal Background
When broken down by race, mortality incidence rates collected during the ongoing opioid epidemic reveal racial disparities that have situated the burden of harm heavily on the Black community. An analysis of the National Vital Statistics System shows overdose mortality trends involving fentanyl and synthetic opioids as well as heroin among Black people beginning to outpace the rest of the population around 2019.9 Additionally, it shows an upward trend in prescription opioid overdose mortality and a stark increase in cocaine overdose mortality during the same timeframe. The authors note that, between 2010 and 2019, overdose mortality in the Black community more than tripled. This was contrasted with a 58% increase among White individuals in the same timeframe.10 While overdose fatalities decreased overall in Indiana between 2021 and 2023, further analysis by race reveals mortality rates that continue to be much higher in the Black community, which bears the highest mortality burden per 100,000 people of any racial group in the state.11 Nationally, rates stagnated, then decreased between 2021 and 2023 as whole, but increased in the Black community during the same period (Appendix A).12 In an effort to understand and ameliorate this disparity, our team has considered ways to reduce the likelihood of death after an overdose. In this study, we focus specifically on calling 911 after an overdose event.
An action frequently taught in layperson overdose response training to bring medical professionals to a scene, calling 911 is recommended to manage the various medical complications one can experience during an overdose.Reference Wagner13 However, this step is fraught for Black lay responders and people who use drugs. Calling 911 after an overdose can be regarded by people who use drugs as synonymous to calling law enforcement,14 making criminalization a possible consequence that is weighed against the benefits of that decision.Reference Latimore and Bergstein15 Additionally, legacies of race-based mistreatment from law enforcementReference Fagan and Bakhshi16 impact Black individuals’ perceptions of police, which have historically been negative for many.Reference Peck17 Because calling 911 is the primary way for laypeople to mobilize medical professionals, we examine how this action is viewed by our study participants and how it can be made safer for the Black community so that overdose victims have access to swift medical care without the risk of legal ramifications. Our paper looks to policy as one of the possible ways this can be accomplished. GSLs address legal risks associated with administering naloxone and being at an overdose event when law enforcement arrives. While somewhat effective, their application requirements in the state of Indiana can limit their protective impact in the Black community.
Good Samaritan Laws Nationwide and in Indiana
GSLs related to opioid overdose response are a series of state laws that provide legal protections for lay responders and, in some states, bystanders and the overdose victim. Designed to reduce fear of legal consequences and encourage people to call 911 after an overdose, GSLs have been part of wider harm reduction efforts to reduce opioid overdose deaths in 48 states.Reference Reader, Walton and Linder18 GSLs have effectively reduced fatalities nationally. A review of the National Vital Statistics System and the National Survey on Drug Use and Health datasets between 2000 and 2014 showed that GSLs were associated with a 26% lower incidence of overdose deaths in Black non-Hispanic populations in the United States. Additionally, the authors found that there was no evidence that GSLs were associated with increased opioid misuse.Reference McClellan19 GSLs mitigate a range of consequences from civil liability to criminal charges, but lay responders must often meet certain requirements.20 GSL protections vary greatly across states. Their complexities and intersections with other state and federal policies as well as police and prosecutorial discretion can reduce their protection or omit it completely.Reference Pamplin21 Even when GSLs provide protection, police discretion plays a role in its distribution. Police may arrest lay responders, witnesses, and overdose victims based on factors that are not always covered by GSLs, such as possession or outstanding warrants, even when officers have been told not to arrest people at overdose scenes so as not to discourage others from calling 911 in the future.Reference Smiley-McDonald22 GSLs only extend as far as “street-level bureaucrats,” such as law enforcement officials, are willing to allow. Complexities and narrow protections along with inconsistent application of GSLs make their utility ambiguous for potential lay responders. Expectations of discretion being wielded by police to nullify legal protections contributes to hesitancy to call 911 due to fear of criminalization, leaving overdose victims with delayed medical care or no medical response at all.Reference Michaud23
Indiana’s GSL, Aaron’s Law (IN Code 16-42-27-2 and 16-42-27-3), provides a range of protections that remove legal barriers to distributing, obtaining, and administering naloxone as well as calling 911 after an overdose.24 The harm reduction impacts of Aaron’s Law25 are in line with the results of other GSLs around the country.26 Despite its protections, Aaron’s Law is still undercut by its limitations. Legal protection from Aaron’s Law is contingent on the layperson administering naloxone, calling emergency services, waiting for emergency medical service and police to arrive, acting in “good faith” and “cooperating at the scene.” It does not protect against criminal liability for parole or probation violations, public intoxication, trespassing, or other crimes committed at the scene of the overdose. Due to the requirements for protection in Aaron’s Law, the individuals who suffer the overdose, those who administer naloxone without calling emergency medical service, those who call but do not administer naloxone, and others at the scene are still at risk of criminalization.27 Of 48 states with GSLs, Indiana is one of 22 that excludes protection for people on parole or probation (as of January 1st, 2023).28 Many areas with high proportions of Black residents in Indianapolis also have the highest proportions of residents who are on parole.29 Given the limitations of Aaron’s Law, people who use drugs in these areas, either recreationally or legally, may be more vulnerable to overdose fatalities as the potential legal consequences of calling 911 are higher for those without its protection.
Racial Disparities and GSLs
In Indiana, GSL limitations place Black communities at a disadvantage due to a combination of past and present racist criminal legal practices and the requirements for GSL protection that involve legal standing. Racial disparities in substance use disorder health outcomes and rates of criminalization are inextricably linked in the United States.Reference Farahmand, Arshed and Bradley30 This linkage is seen in Bailey et al.’s conceptualization of structural racism in their review of its role in health inequities. In their work, they demonstrate how inequitable systems “reinforce discriminatory beliefs, values, and distribution of resources, which together affect the risk of adverse health outcomes.”Reference Bailey31
Black communities have experienced a long history of mistreatment from police and unequal application of the law. President Richard Nixon’s “War on Drugs” continues to impact communities as the echoes of its harsh policing and sentencing policies as well as “societal stereotypes of minority criminality” persist.32 This history reveals overpolicing as a threat to the Black community, which can make calling 911 a risky action. In a 2014 report for the Sentencing Project, authors Mauer and Ghandnoosh observed that two-thirds of the people incarcerated in state prisons for drug offences were people of color, and that Black individuals were three times more likely than their White counterparts to be searched and twice as likely to be arrested during a traffic stop.Reference Mauer and Ghandnoosh33 A report for the RAND Corporation noted that this imbalance is an upstream contributor to the racial disparities in parole and probation rates. The report adds that Black individuals are over two-and-a-half times more likely to be on probation and close to four times more likely to be on parole than their White counterparts. Additionally, they are likely to experience more conditions of release.Reference Russo34 Additionally, Black men and women are more likely than their White counterparts to experience fatal encounters with police.Reference Edwards, Lee and Esposito35 A national survey of first responders showed that police tend to ascribe “deservingness” of aid after an overdose more readily to White people than to their Black constituents. Considerations of deservingness are also lower for police who have responded to 40+ overdose calls,Reference Lofaro36 potentially making areas that have high rates of overdose calls and areas with predominantly Black residents more vulnerable to police discretion toward punishment.
The inequities of Aaron’s Law reflect a larger trend in GSLs across the country, revealing weaknesses related to structural racism within both policing and prosecutorialReference Davis37 systems. Pamplin III et al. note that policies written to decrease harm from the opioid epidemic leave Black communities behind as they are undercut by narrow application parameters, countered by laws that further criminalize people who use drugs, and contain vague wording, leaving their application up to police discretion.38 Examples of vulnerabilities in Aaron’s Law (IN Code § 16-42-27-2) are in subsection d, which notes the administrator must be “acting in good faith,” and subsection g, which lists requirements for protection from possession charges that include providing “relevant information” and cooperating with emergency response and law enforcement. Good faith, relevant information, and cooperation are not otherwise defined and are left for the officer to make a “reasonable determination.”39 The law does not provide protection from technical violations of parole or probation, nor does it protect against arrest for an outstanding warrant. In their 2022 article, Lopez et al. introduce a “framework of unmet obligations” from harm reduction efforts of which their third construct, racialized criminalization, highlights the disparity in the application of opioid harm reduction policies like GSLs. They call for critical reflexivity of implicit and explicit racialization in the creation of harm reduction initiatives and policies, noting their context within structurally racist institutions.40
The effects of GSLs with narrow parameters of protection is the reinforcement of a criminal legal structure that provides unequal protection for people who assist after an overdose. We surmise that this is an upstream factor impacting the decision of Black lay responders to call 911 or not. Policies can lay the groundwork for how police are held accountable to their treatment of their constituents. If police respect policies that prioritize the health and wellbeing of individuals experiencing an overdose and save lives rather than criminalize them, people’s perceptions may change, and lifesaving behavior such as calling 911 may follow. Hamilton et al. demonstrate that a path from policy to individual behavior is possible through perception change. They found that GSLs that protected laypeople from arrest at the scene was correlated with a 7% decrease in overdose deaths two years after the laws were passed.Reference Hamilton41 This example demonstrates how protection from arrest creates a scene of care rather than criminality and can lead to a gradual community-wide perception change that ultimately saves lives. Our study of MACRO-B participant interviews aims to explore that path by analyzing the accounts of people in communities heavily impacted by overdose mortality. We detail these accounts next. Then, by centering their perspectives, we will consider how Aaron’s Law, and others like it, can be amended into a more equitable and protective harm reduction policy.
3. Empirical Study Methods
The analysis described in this paper is part of a larger study in collaboration with our community partners, who encompass various grassroots organizations, Black residents who experienced nonfatal overdoses, family members of people who have had fatal overdoses, law enforcement, local emergency medical services, local nonprofit organizations, decision makers at local and state governments, and local and state-level legislators. Four Marion County zip code areas — 46202, 46205, 46208, and 46218 — are the focus of the study. They were chosen due to their locations within inner city Indianapolis, their higher proportions of Black residents when compared to other locations in Indiana,42 and their high rates of opioid overdose deaths.43 All interviewees in the study were Black residents of these zip code areas. Additionally, the interviewer was a Black resident of Marion County who is in recovery, making her particularly attuned to the study participants as a trusted community member.
To explore the relationship between participants’ beliefs about law enforcement and their willingness to call 911 after an overdose, we opted to use the Health Belief Model. The Health Belief Model breaks down belief-based constructs related to health behaviors and provides a theoretical framework for their role in decision making.Reference Glanz, Rimer and Viswanath44 By using the Health Belief Model as our guiding framework, we were able to identify possible patterns in the relationship between participants’ experiences with and perceptions of law enforcement and their beliefs about the benefits and barriers to calling 911. The Health Belief Model theorizes that these beliefs can predict prevention, treatment, and risk reduction behaviors, so learning how they are influenced can be a useful component in adjusting the targeted behavior in a way that improves health outcomes.45 While the Health Belief Model is a model primarily used to analyze individual health behaviors, we found it to be an appropriate mechanism that demonstrates why individual beliefs should be considered in policy making, especially when those policies affect influential factors of belief.
Burris et al. note that legal epidemiology can inform the mechanism of an effect (such as disparate overdose deaths) by evaluating the “process through which a law…influences behavior or environments….”Reference Burris, Cloud and Penn46 We took a qualitative approach to legal epidemiology and explored this mechanism by assessing how GSLs might influence the behavior of the focus area residents following an overdose, based on residents’ own narrations. Their perspectives provide insight into how policy and beliefs might manifest in the daily lives of the residents. Using the Health Belief Model framework, we examined how beliefs about benefits and barriers to police presence impacted the decision to call 911, what might influence those beliefs, and how policy impacted the context in which influential events and perceptions were fostered and decisions were made.
We focus on a corpus of 50 semi-structured interviews. The study designers chose this number to achieve saturation across various inquiries of the data set and to attempt to fully capture Black residents’ narratives and perspectives on structural racism and overdose deaths. When recruiting participants, we used a blended approach in which we employed homogenousReference Creswell and Guetterman47 and snowballReference Merriam and Tisdell48 sampling to achieve saturation. All of the 50 interviewees were Black adult residents of the target zip codes. Ten open-ended questions were developed through discussions between the research team and the coalition of community partners described above. Interviews were conducted by a Black woman who was part of the coalition. She was an ideal candidate to conduct interviews due to her professional experience in the field of overdose prevention and substance use disorders. Her position as a fellow person of color, a person in recovery, and an active participant in the Civil Rights Movement contributed to her ability to garner trust from the participants. The interviewer engaged in a relaxed and supportive conversational style, using probing questions, paraphrasing, and restating questions as needed and in different terms to adjust to the participant’s needs. Participants were given information about the study and provided consent prior to the interviews. The protocol of this study was approved by the Institutional Review Board at the lead author’s institution. Names and contact information were not retained and anonymity was a priority due to the sensitive nature of the subject. Each participant’s time was compensated with a Walmart gift card at $50 per hour.
Because this analysis of the interview data was planned after data collection, we used the steps of Directed Qualitative Content Analysis detailed by Assarroudi et al., starting at Step Seven, “being immersed in data” (see Appendix B).Reference Assarroudi49 The coding authors met daily over five days to create and test four versions of a codebook by independently applying each version with a selected interview per version of the codebook. Coding authors then came together to compare and reach consensus with each new version, with an addition of a fourth researcher affiliated with the larger study to test the final version of the codebook. One author used the final codebook to code and analyze verbatim transcripts of the interviews in MAXQDA version 23.3. Codes were organized in MAXQDA and applied to each interview. The Code Frequency Tool was used to generate graphical information on code frequency at the code level and the document level and to get a general overview of trends in the interviews. The Analysis and Visual Tools were then used to identify patterns and isolate excerpts related to those patterns. Finally, we engaged in an iterative process of meaning making by immersing in the isolated excerpts and further categorizing them based on the thoughts and beliefs they constructed using the Smart Coding Tool and memos. This enabled us to build an understanding of how the Health Belief Model applied to participant experiences based on a reflexive interpretation of their narrations.
Coded Concepts
Because the Health Belief Model is used for individual-level behaviors, it allowed us to view policy decisions and the impact they have on the context of an overdose from the perspective of the people affected by them. We focused on two Health Belief Model constructs that are the strongest predictors of one’s decision to engage in a health behavior: perceived barriers and perceived benefits. Reference Carpenter50 Perceived barriers reflect one’s beliefs about the obstacles to the behavior and the negative consequences if one engages in that behavior. Perceived benefits are the beliefs one has about what they can gain or how the behavior might be helpful.51 These constructs attend to the “mental barriers” experienced by the Black community to engaging in lifesaving behaviors following an overdose.52 In addition to the above Health Belief Model constructs, our original anchor codes also attended to experiences and perceptions to explore their relationships with beliefs about benefits and barriers. “Experiences” included firsthand experiences as well as narrations wherein participants discussed the experience of someone they could identify directly (such as a family member, friend, client, or coworker). This second type of experience was important to note due to its role in sensemaking and appraising the threat presented by law enforcement.Reference Difonzo, Bordia and Pratkanis53 We also attended to “helpful” and “positive” experiences with police during which police provided resources, assisted in caring for an individual’s health and wellbeing, and/or engaged in conversation that a participant found to be overall positive. This reflects work by Peyton et al. that explored the impact of conversations rooted in Community-Oriented Policing concepts on perceptions of legitimacy and trust towards police.Reference Peyton, Sierra-Arévalo and Rand54 “Perceptions” attended to the beliefs participants held about law enforcement and the legal system as a whole. Parent codes are detailed in Appendix C.
4. Interview Results
Overview
When analyzing code frequencies in each interview (Appendix F), a few patterns emerged. We found that a large majority of the 50 participants discussed negative perceptions of law enforcement (43) while fewer described positive perceptions of law enforcement (19). Many participants shared their negative experiences and/or instances when someone close to them had a negative experience with police (33). Most of the participants also believed that racism was a factor (41) in police interactions and other experiences when calling 911 or getting first responder assistance following an overdose. Within the Health Belief Model constructs, low benefits to calling 911 (36) were identified most frequently, followed by high barriers related to consequences of calling 911 (30).
When analyzing segments of the interviews with overlapping code frequencies, we observed that negative perceptions were most often discussed alongside appraisals of low benefits (57 intersections) and high barriers (49 intersections) (Appendix G). Negative or unhelpful encounters with police most often paired with appraisals of low benefits (36 intersections) while positive or helpful encounters intersected with high appraisals of benefits (23 intersections) (Appendix H). While the highest rate of intersection occurred between negative perception and assessment of low benefits, the alignment of negative perception and assessment of high barriers was the most diverse, with participants relating high barriers to a larger variety of reasons. Excerpts in which participants noted high benefits to calling 911 were more frequently discussed alongside experiences rather than perceptions and contained examples of times that a perception was changed by a positive experience with police.
Low Benefits
Low benefit was the most frequent Health Belief Model construct discussed, with slow response time being the primary reason participants expressed this belief. One interview question asked participants to discuss their perception of timeliness when 911 was called to the scene of an overdose. This likely accounts for how often timeliness was discussed and why a high percentage of interviews contained instances of low benefit codes, since every participant engaged with the topic for at least a small part of the interview.
Many participants expressed their belief that the location of the overdose determined the speed of emergency response, noting that the areas they lived in had a high frequency of overdoses and that they had high concentrations of Black residents when compared to other parts of Indianapolis. Suggested explanations behind slow response times were beliefs that police considered the focus areas to be dangerous and/or undesirable and police burnout after responding to the same area multiple times for the same issue without the expectation that it would be helpful. Comparisons were frequently made between more affluent communities that had fewer Black residents and those with larger percentages of Black residents.
[Police] don’t like coming to quote unquote ghettos, you know. They’d rather pull up and, even though it’s getting better, it’s proportionally more Black people that are living in impoverished neighborhoods. So less response, slower response rates into those areas specifically. Whereas on the other end, it’s a [redacted] overdose and they’re there in two seconds. (Participant AC)
Some participants discussed substance use stigma that led emergency services to not take overdoses seriously, and a couple others reported that police were not helpful or did not seem to care when they arrived at an overdose scene.
Even as a kid, like when the police came for my mom and my stepdad, many police didn’t care. I remember a cop looking at me when I was a little kid and he said, “I don’t give a…” you know, and I was like, whoa, okay. I guess nobody cares about, you know, my mom getting beat up. Because they’re just used to it and everyone’s used to it.(Participant AN)
High Barriers
Most barriers were regarding potential consequences of calling 911. Many participants who had experiences with overdoses at which 911 was not called recounted the fear of legal repercussions. Some were concerned with civil liability and expressed concern over accidentally hurting the victim or being blamed for their death. Most participants described fear of criminalization for being associated with illegal substance use, being under the influence, or police finding another reason to arrest them. “What we’ve seen already is some adverse issues with police not having that compassion and just being more about law-and-order handcuffing, holding people down, that kind of thing” (Participant BD). Some participants who knew about GSLs were concerned that police either did not know Aaron’s Law or would not honor the protections it provides. “I’m running from you, the police, man. I’m, I’m gone. I don’t know about no law. You don’t even know nothing about the law. [Indianapolis Police Department], you need to be educated about Aaron’s Law because your initial thing is to arrest” (Participant AR). A couple participants recounted not knowing to call 911 or believing that they or others could themselves care for the individual who overdosed without involving emergency services.
Race was a common factor in excerpts about high barriers. Participants reported concern that their race made them more likely to be mistreated by police and that law enforcement did not want to protect them, a fear that is based on the history of racism in drug policies in the United States.55 Multiple participants described the perception that Black substance users were treated as criminals while their White counterparts were seen as having an illness. “You say we playin’ chess, but you give me a checker piece and expect me to still win and know the moves” (Participant AR). These concerns reflected accounts of fear of mistreatment56 or harm,57 an expectation of criminalization58 and arrest,59 and mistrust60 in law enforcement described in other studies. Some expressed frustration over law enforcement who seemed inclined to harass rather than get to know the people in their community. Negative encounters with law enforcement both firsthand and of loved ones were sources of mistrust. “I have dealt with the law. So it makes you, it makes you wonder if it is gonna be okay, you know, submit what I need to tell you or it just gonna be used against me” (Participant AS). Some participants expressed an expectation of brutality or criminalization without recounting first or secondhand experiences themselves, with a couple noting the impact of learning about police brutality through media. “Because of the, the rise of the police brutality, I think it’s more so, you know, people just fearing for they life in general” (Participant AB). Other cited histories of police mistreatment and brutality along with current issues of racism among law enforcement.
I believe that race is playing a big part in today’s world in a lot of situations. And you would think that it’s not like that anymore because we’ve come past that and, you know, it’s supposed to be equal rights, but in the past three to four years, race has been a big thing with the first responders in the community, the police, the ambulance, it is just always a problem with the Black community to be exact. And I do believe it’s because they believe that we’re the aggressors you know, we’re aggressive and it, it could come from history and past and, you know, that everything follows. But we were supposed to break that chain and it’s coming back around, unfortunately. (Participant AY)
The presence of race in excerpts reflecting high barriers contrasts with discussions of timeliness and low benefits, which were more often related to location and wherein race was part of the reason for a location being stigmatized but was not explicitly cited by the participant in the excerpt. We found that participants would often name racism as a reason for the police mistreatment they feared. Discussions of location were less directly tied to racism but were often connected to observations that participants’ neighborhoods had fewer resources, more crimes, and were viewed less favorably by police than more wealthy areas of the city. Some participants shared their belief that these community conditions existed because of the high percentage of Black residents in those areas, while others focused more on low socioeconomic status as a contributing factor. In some of the excerpts, the discussion of location and low benefits came after their reflections on the impacts of structural racism in their neighborhoods.
High Benefits
Participants who expressed positive perceptions of law enforcement and/or positive and helpful experiences were generally willing to call 911 after an overdose. Appraisals of high benefits were more often shared when participants described experiences than perceptions. After positive/helpful experiences with police, some participants who expressed high barriers and mistrust of police in general still regarded them as potentially helpful in overdose situations and felt that the benefits outweighed the risk of consequences to themselves.
I think that’s a big problem. Like in our community, we don’t wanna call the police. We don’t want the problems. Most times we’re doing something extra that “if they come now, I might be in trouble too.” But I mean, I’ve seen them called, I’ve seen them not called, and most times when they’re not called, that’s when it becomes fatal. Um, I have seen them called and people have survived. (Participant BI)
A couple participants described a change in perception related to the realization of the benefit after witnessing police help in an overdose situation.
So, the police have been in my house and it’s never been, it hasn’t been…I’ve had altercations, not necessarily altercations, but, um, our interactions was not good because I’m standing up for my Black son…So I kind of got that negative thing. But I have to admit that when they came to my house for the several times that they were called for, you know, for the overdoses at my house, they were more compassionate than I expected. And so, like, I was really shocked at the compassion. I remember one officer, but he was Black and he’s like, he was just talking to me, not really knowing where I was, you know? (Participant AK)
Please see Appendix D for more quotations from our participants.
5. Discussion
The intersection of slow, unhelpful, or risky police response after an overdose and historic overpolicing of Black individuals61 come together into the belief that police don’t see their role in Black communities as one of protection but of enforcement.Reference Bonner62 This sentiment is shared broadly in communities with similar demographics,63 punctuating the strained relationship between law enforcement and minority communities64 and its impact on the decision to call 911 after an overdose. The effect incidents of race-based police brutality have on individual decisions is reflected in a study examining the impact of the police beating of Frank Jude, an unarmed Black man in Milwaukee, Wisconsin. The authors found that this event significantly reduced the number of calls to 911 from Black citizens for about a year.Reference Desmond, Papachristos and Kirk65 Lopez et al. noted that “historical experiences and current fear of enforcement…[intersect] with feeling less protected by the harm reduction infrastructure.”66 This feeling, while held by the individual, scaffolds community perceptions of law enforcement. Its influence on the desire to call 911 can have life-threatening implications on people experiencing an opioid overdose. The reluctance to call 911, thus risking a punitive police response, is not unwarranted. Structural racism’s presence in policing is well documented. Black people experience higher rates of incarceration for drug-related activities,67 are more likely to have fatal interactions with police,68 and make up a disproportionately large percentage of people on parole or probation.69 Nationwide, police tend to see Black overdose victims as less deserving of aid when compared to their White counterparts.70 It is necessary to take structural racism’s manifestations in criminal legal institutions and in former and current drug policy into account when examining health disparities because it is often a contributing factor.71 The fear and mistrust related to histories of racism in the criminal legal system are supported by the narrations of our participants. Many felt that police were uninterested in rendering aid and described fear that they would be mistreated if police found them at an overdose event. Participants also expressed unwillingness to call 911 after an overdose, linking this to their assumption that police would arrive and that there were few benefits and significant barriers that could result from the call.
Promisingly, some interviews demonstrate that positive encounters with law enforcement were influential in appraisals of the high benefits to calling 911. The expectation that aid would be rendered effectively appears to be powerful, especially after seeing it occur or knowing someone who experienced a benefit. In some cases, people who described high barriers and/or negative perceptions were willing to call anyway, largely because of this. We cannot erase a deep history of violence, nor can we ask people who come from legacies of oppression to simply forget all of it. However, we can foster an environment in which helpful and restorative police interactions are more likely to occur. This reflects the independent nature of perceived benefits and perceived barriers:72 even while the barriers are high, increasing benefits can encourage laypeople to dial 911 despite the risk, because the reward of a saved life might be greater.
Policy changes are an important step in fostering a more hopeful environment. Per Frieden’s Health Impact Pyramid, policy changes have been one of the most wide-reaching impacts on the improvement of health outcomes.Reference Frieden73 Clear policies that protect lay responders can create accountability for law enforcement, hopefully leading to actions that are lifesaving and focused on protection rather than punitive enforcement. Policy may influence individual actions of police, which have great bearing on how the community perceives them and their behaviors based on those perceptions. A study in New Haven, CT, provides support for the positive impact of nonenforcement police encounters wherein officers focus on communicating with residents with the goal of community improvement. The authors found that these encounters improved attitudes towards police, willingness to work with police, and perceived legitimacy. This effect was particularly large among Black participants and participants who held negative views of police prior to the intervention.74 A later study that examined the relationship between perceived legitimacy of police and willingness to call found that this willingness, in the case of serious issues, was positively related to perceptions of trust and value alignment.Reference McLean75 Additionally, this path is supported by Hamilton et al., who found that the passage of GSLs that protected people at an overdose scene from arrest was correlated with a 7% reduction in overdose deaths two years later.76 They believed that this was because the legal context contributed to police encounters focused on medical assistance. These studies support the idea that improved perceptions of police, particularly through encounters in which police are supportive, can increase the likelihood of someone calling 911 after an overdose. Applying the Health Belief Model framework, this might be because of an increase in the belief that calling 911 and having police respond to an overdose event is beneficial.77
Indiana is one example of a state where GSLs can be strengthened to provide increased equity of the protections they provide. Because Black individuals are more vulnerable to discretionary law enforcement practices that tend towards criminalization78 and are more likely to be on parole or probation,79 policies that vaguely require cooperation with police and do not protect against technical violations perpetuate racial disparities in opioid overdose deaths by increasing risk in an overdose environment. Eliminating narrow parameters and supplying clear language around the restorative mission of overdose response and protections afforded people at the scene can direct police to prioritize aid and hold them accountable rather than placing vague burdens of compliance on lay responders. Removing the exclusion of protection for people on parole or probation reduces the chances that a caller would be charged with a crime after assisting at an overdose scene, making GSL protections more equitable across communities that experience high rates of criminalization. Eliminating the chances of arrest altogether is preferred, offering witnesses a chance to see how emergency responders can help and potentially making them more likely to call 911 in the future.
Policy Recommendations
The strongest GSLs make it clear that, after calling 911, Good Samaritans and the overdose victim are not in violation of substance use-related laws or probation/parole violations,80 making legal protection the rule rather than the exception81 so that there is no ambiguity for law enforcement who arrive at a scene. As such, we echo calls from others in recommending that policy makers widen the criteria for protection of GSLs by eliminating exceptions to protection, such as quantities of illegal substances in possession of the caller/victim, limits on the number of calls one can make and remain eligible,Reference Salim82 and requirements such as administering naloxone, compliance, and answering police questions. We recommend that GSLs include protection from probation/parole violations83 and protect the caller and victim from arrest rather than just charge, prosecution, or sentencing mitigation.84 We also assert that GSLs related to overdoses should be uniform across the country.85 As such, their implementation could benefit from them becoming a federal policy.
Policies written with reflexivity and the reality of structural racism in mind can disrupt racial disparities and ensure the purposes of GSLs are enacted.86 These changes have the power to improve the environment in which 911 is needed so that individuals who overdose are more likely to receive help and witness police interactions that demonstrate protection and care rather than criminalization and fear. Over time, beliefs around calling 911 may change, with perceived benefits increasing and perceived barriers decreasing, potentially increasing the likelihood that 911 will be called after an overdose and the victim will survive. We believe these changes can address the increasing overdose fatality rates and reduce the incidence of opioid overdose deaths in the Black community.
Research Recommendations
While our policy and empirical analysis support much of our argument, part of this work leans on inference and logical steps through areas where there are significant gaps in the literature and that our data did not directly address. There is little but emerging literature on the impact of GSL ambiguities on attitudes towards police interaction and calling 911 after an overdose. There is less work regarding GSL specificities and changes that improve outlook and willingness to call 911. We call for future studies to examine citizens’ impressions of GSLs and the extent of their protection, both to assess how GSL parameters impact citizens’ intentions to call 911 and to elicit ideas for legislative change that could increase their willingness. We also call for legal epidemiological approaches to harm reduction policies that take structural racism into account. Legal mapping and quasi-experimental evaluation of GSLs that attend to their variations across the United States may lend insight into strategies that can ameliorate race-based disparities, as can continuous and improved surveillance of harm reduction policies. Qualitative approaches can give researchers an increased and nuanced understanding of how GSLs impact individuals and provide direction for policy change. Finally, examining the precedence set in cases in which GSLs provided protection or in which they were used in legal proceedings and making that information available to both legal teams and harm reduction agencies would be useful in empowering and protecting would-be lay responders.
Beyond This Scope
Our recommendations for policy reform are a product of the institutions and resources currently available. However, we hope for a different future. We believe that legal response to an overdose, which is primarily a medical event, is not always appropriate. Given the medical needs and the valid mistrust of law enforcement following an overdose, we call for interventions that use police involvement as a last resort. For example, emerging interventions, such as 988 for mental health crisis response and overdose response teams equipped to address medical and mental health challenges as well as engage in compassionate de-escalation, offer critical and swift responses that center care rather than enforcement. Sustainable and wide-reaching efforts to reduce race-based disparities and address inequities brought on by racism and stigma must consider and address the structures and institutions that reify them.
Limitations
Qualitative inquiry calls the researcher to consider the built reality of the people who provide their accounts and the communities they belong to. Thus, the results of this study are not generalizable, but focus on joining the voices of people whose experiences of structural racism are not often considered. Most of the authors of this paper have not experienced the legal system in the way our participants do. We acknowledge that our interpretation is influenced by this. Due to our interviewer’s proximity to the community and her experience with substance use, we acknowledge that her positionality could also have an impact on the interviews. GSLs vary greatly across the country, and little has been published with empirical evidence on how their many facets impact mortality. As such, we must sometimes lean on inference to draw connections between policy and its impacts on minoritized communities. We are confident in these connections and urge readers to consider the gravity of their reality and the realities of the participants who gifted us their interviews. We recognize that policy alone will not end race-based police violence. Accountability is key and, even then, individual police action may not align. There are broader and deeper needs to address the roots of racism in the United States that will take many more people, papers, partnerships, and beyond to heal.
Supplementary material
The supplementary material for this article can be found at http://doi.org/10.1017/jme.2026.10244.
Acknowledgements
This work would not be possible without Overdose Lifeline (ODL). ODL was founded in 2014 with a key mission of increasing access to the overdose reversal drug naloxone which at the time required a prescription. With assistance from ODL, the Multi-Sector and Multi-Level Community-Driven Approaches to Remove Structural Racism and Overdose Deaths in Black Indianapolis Communities (MACRO-B) Project distributed a total of 95,000+ naloxone (Narcan) units and 55,000 fentanyl test strips; installed 40 NaloxBoxes; and, most importantly, reduced overdose deaths by 45% among Black residents in the target Indianapolis communities within two years of the project.
We are grateful to our participants for taking the time to share their stories, especially considering the sensitive nature of this topic. We are also appreciative of the MACRO-B coalition members, who drive this work and hold us and our inquiry accountable. Thank you to the Indiana Department of Correction’s Data Science and Analytics Department for their cooperation. We are grateful to Dr. Rachel Tin for her guidance of this paper. Finally, we would like to acknowledge the people whose lives have been cut short or harmed because of structural racism in our justice system. We can do this work because their sacrifice is bringing attention to how far we still have to go.
Funding
This MACRO-B Project is supported by the Office of Minority Health (OMH) of the U.S. Department of Health and Human Services (HHS) as part of a financial assistance award (CPIMP221346) funded to Dr. Seo by the OMH/OASH/HHS. The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement, by OMH/OASH/HHS, or the U.S. Government. For more information, please visit https://www.minorityhealth.hhs.gov/.
Disclosures
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This work was supported by the Office of Minority Health (OMH) of the US Department of Health and Human Services (HHS) as part of a financial assistance award (grant number CPIMP221346).
