More than Medicine: The Complex Choreography of Community Overdose Response

More than Medicine: The Complex Choreography of Community Overdose Response | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article More than Medicine: The Complex Choreography of Community Overdose Response Adams L. Sibley, David C. Colston, Elizabeth Joniak-Grant, Blair Coleman, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-9140958/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract The practices of lay responders remain poorly understood despite overdoses increasingly occurring outside medical settings. This qualitative study examined how 74 people who use drugs in Pennsylvania, Michigan, and California reverse overdoses in real-world conditions. Semi-structured interviews explored participants' overdose response experiences across hundreds of reversals. Reflexive thematic analysis informed by Critical Decision Method identified two types of critical moments that shape response trajectories: inflection points requiring decisions, and friction points creating obstacles. We organized the findings into four themes: (1) the interplay between preparation and adaptation, with responders departing from standardized approaches based on contextual factors like suspected drug type and characteristics of the person overdosing; (2) perceptual and material precarity (e.g., time distortion, incomplete information, and device failures); (3) managing bodies, spaces, and social dynamics (e.g., breaking down locked doors and controlling panicked bystanders); and (4) ethical tensions around dignity, autonomy, and precipitated withdrawal, with most participants having experienced withdrawal themselves. Participants navigated these complexities through pattern recognition, improvisation, and experientially developed heuristics. Despite facing multiple simultaneous overdoses, hostile environments, and material constraints, few participants reported unsuccessful reversals. Participant accounts reveal that overdose response defies simple procedural steps, requiring embodied knowledge developed through experience. Findings suggest value in trainings that build adaptive expertise, having multiple naloxone formulations available including intramuscular options, and providing support systems for community responders. People who use drugs overdose harm reduction naloxone peer care overdose reversal qualitative research Introduction In 2023, 76% of the more than 100,000 overdose deaths in the United States involved opioids, primarily illicitly manufactured fentanyl [ 1 ]. The mu-opioid receptor antagonist naloxone is a safe and effective medication used to reverse opioid overdose [ 2 ]. Available to medical professionals since 1971, naloxone has been distributed by harm reduction activists in community settings since at least the 1990s [ 3 ]. Take-home naloxone programs became a model for overdose prevention by the mid-2000s, though with little governmental support at that time [ 4 – 6 ]. Much of the early and ongoing success of these programs was due to the efforts of non-profit “naloxone buying clubs” that have bulk-ordered millions of doses of naloxone to distribute at low or no cost to partner programs. Over the last decade, state and federal policies have recognized these crucial efforts and prioritized naloxone saturation strategies to ensure the life-saving medication is available wherever and whenever it is needed [ 7 , 8 ]. Overdose education and naloxone distribution has likely played a crucial role in the recent downturn in overdose mortality nationally [ 9 ]. The overdose crisis is fundamentally a community-managed public health emergency, though the true scope of community overdose response remains vastly underestimated. Emergency medical service (EMS) data suggest that only 3.4% of EMS activations feature lay responder-administered naloxone [ 10 ]. However, these data fail to capture the many reversals where 911 is never called. A recent cohort study in San Francisco and Boston found that EMS was activated in fewer than half of overdoses, while retrospective data from a Pittsburgh syringe service program documented that 92% of participant-reported reversals were conducted without EMS involvement [ 3 , 11 ]. One online panel survey found that 60% of people with opioid dependence report carrying naloxone at least occasionally, compared to 10% of the general population [ 12 ], indicating that those closest to risk have become de facto first responders. This community preparedness represents a remarkable public health achievement: people who use drugs and their networks have created an informal emergency response system operating largely outside of the medical infrastructure. Yet this community-led response system remains poorly understood by public health institutions, despite its role as the first line of defense in the chain of overdose survival [ 13 ]. Training protocols for bystanders, disseminated through overdose education and naloxone distribution initiatives, assume standardized conditions, including unambiguous symptoms, an orderly environment, and ready access to supplies. These protocols outline a linear sequence of actions—positioning the individual, administering a full dose intramuscularly or intranasally, calling 911, and waiting while providing CPR if able [ 14 ]. Such guidance reflects an idealized representation of overdose response. In practice, community responders face fundamentally different realities marked by panic, distractions, and multiple decision cascades [ 15 ]. They navigate these challenges without formal medical training, often while using drugs themselves, and nevertheless successfully reverse overdoses that are not captured in official surveillance systems. Understanding how community members successfully manage overdose events is essential for effective public health response. This qualitative study examines the experiences of 74 community members who have reversed overdoses in Pennsylvania, Michigan, and California, revealing the complex physical, psychosocial, cognitive, and ethical challenges they navigate. Their accounts demonstrate that overdose response defies standardization, requiring embodied knowledge that cannot be taught through protocols alone. Recognizing and integrating this community expertise is crucial for developing realistic training programs for lay responders, informing distribution strategies, and ultimately reducing overdose mortality. Methods Data Collection Data were collected as part of a multi-modal investigation of layperson naloxone administration, which included longitudinal analyses of overdose reversal trends using historical survey data from an established syringe service program [ 3 ] in addition to the in-depth interviews presented in this manuscript. Participants ( N = 74) in this qualitative study were a convenience sample recruited from harm reduction programs or by peer referral in western Pennsylvania ( n = 27), western Michigan ( n = 25), and central California ( n = 22). Inclusion criteria were: 1) aged 18 years or older, 2) administered naloxone in past 12 months, and 3) currently using drugs with overdose risk or have social contacts who use drugs with overdose risk (“Do you or the people you hang out with use drugs that could cause overdose?”). Prospective participants self-selected into the third category based on their own interpretation of “drugs that could cause overdose” and/or “the people you hang out with.” The three partner programs assisted in identifying potential participants. All three programs ask clients requesting naloxone if they have recently reversed an overdose as part of routine program operations. These clients were informed of a research opportunity, and if they expressed interest, were introduced to a study team member to learn more. Prospective participants were screened on-site and offered to participate immediately or schedule for a later date. MI and CA participants were all screened and interviewed in a private office at the program’s brick-and-mortar location. PA participants were recruited from the program’s brick-and-mortar location or one of three mobile sites. PA interviews were conducted in the program office or in private areas adjacent to the mobile locations (e.g., cars, library meeting rooms). Semi-structured in-depth interviews were conducted between October 2024-March 2025 by the first author and a trained research assistant with lived experience of substance use. Topics in the interview guide included: local changes in the drug supply, harm reduction attitudes and behaviors, preferences and recommendations for different overdose reversal agents and formulations, and experiences reversing overdoses. All participants were asked to walk through a recent, memorable overdose reversal from beginning (“Can you walk me through what was going on that day?”) to end (“What happened to [person] after this overdose?”), including details about overdose identification, naloxone administration, supportive interventions (e.g., rescue breathing), and post-overdose events (e.g., after care, disposition to emergency medical services). Participants were also asked about general reversal experiences (e.g., “Has there ever been a time when someone was overdosing and things didn’t go well? What happened?”). Additionally, those who had reversed multiple overdoses were asked to share information about changes in their experiences over time. Community advisory board members from the PA site (all with lived or living experience of substance use) reviewed the interview guide and provided suggestions on question wording and additional probes. Interviews averaged 45 minutes and were incentivized with $ 50 cash. All interviews were audio-recorded and transcribed with the whisper package in Python 3.9 then manually corrected by study team members. Analytic Approach We conducted a reflexive thematic analysis [ 16 ] informed by the Critical Decision Method (CDM) [ 17 ]. CDM is a knowledge elicitation and analytic method for understanding decision-making in complex environments. The method has previously been used to explore proficiency in high-pressure professions, e.g., firefighting, battlefield command, and emergency medical response [ 17 – 19 ]. Importantly, CDM emphasizes that perceptual and contextual learning are critical complements to factual knowledge in developing expertise [ 17 ]. Analysis employed a mixed inductive-deductive approach, with deductive codes situating our analysis around recognized steps in overdose response while remaining open to emergent patterns in participants' accounts. Analytic Process ALS transcribed interviews, during which he engaged in initial familiarization through memoing. Our analysis involved an iterative, recursive process moving between data familiarization, coding, and theme development. We began with open coding of four transcripts by two research team members (ALS and DCC), working independently to identify patterns relevant to overdose response decisions and experiences. Through discussion of these initial codes, we developed a flexible coding framework that combined: Deductive organizational codes structured around major overdose response steps (e.g., overdose identification, naloxone administration); Sub-codes informed by Critical Decision Method to capture decisional cues and contextual constraints; Inductive codes arising from close engagement with participants' accounts. This framework served as a sensitizing tool, evolving iteratively throughout analysis as we refined codes to better capture meaning and incorporated new interpretations of the data. The coding process involved initial double-coding of three transcripts with discussion after each to develop shared understanding of code application, followed by independent coding of remaining transcripts (ALS and DCC). Throughout coding, ALS developed preliminary patterns of meaning and engaged the full research team in three reflexive discussions about emerging insights, ultimately focusing our analytic lens on the tensions between protocol and practice in real-world overdose response. Theme Development Following coding, ALS collated coded excerpts and engaged in intensive memoing to identify patterns of shared meaning across the dataset. Initial theme development focused on inflection points and decision cues in overdose reversals. Through recursive engagement with the data—returning to full transcripts, coded excerpts, and memos—themes were refined to capture the precarity and situated complexity of overdose response. All coding and analysis were conducted in NVivo 1.7.2. Reflexivity Authors include researchers in an academic harm reduction lab (ALS, DCC, EJG, ND), harm reduction practitioners (AB, MV, SA, SJ, MDS, EJW) and FDA staff (BC, JM, ZDWD). This team carries diverse perspectives and extensive experience in harm reduction research and practice, emergency medicine, and qualitative health research. By bringing together stakeholders from multiple backgrounds, the conduct of this research balanced the practical aim of informing overdose policy and practice and the theoretical aim of capturing the embodied experiences and expertise of lay overdose responders. The group met monthly to discuss how the conduct of the research might impact the data collected, and how the data collected might inform analysis. This balance was especially evident in the epistemological and analytical treatment of our findings and interpretation. On the one hand (post-positivist), overdose response is understood as a series of discrete, sequential steps that can be captured through systematic inquiry. On the other (interpretivist), these experiences are inherently situated and contingent, and overdose response cannot be fully explained as a rational process. Our Results and Discussion attempt to honor each of these perspectives and aims. Ethical Considerations The study was approved by the University of North Carolina-Chapel Hill Institutional Review Board (#24–0265) and received a Paperwork Reduction Act waiver under the Department of Health & Human Services’ declared Public Health Emergency regarding the opioid crisis allowing the collection of personal health information with HHS review and approval, without requiring additional approval by the Office of Management and Budget. A waiver of written informed consent for interviews was approved by the UNC IRB for participants to minimize risks associated with creating signed records of sensitive information. Verbal consent was obtained and documented by interviewers, with no signatures or identifying information collected. Demographic data are not presented as a result. Pseudonyms are used throughout this manuscript. Role of Funder The study was supported by the U.S. Food & Drug Administration Center for Drug Evaluation & Research under a broad agency announcement (75F40122C00193, PI Dasgupta). As part of this partnership, FDA scientists identified priority research questions pertinent to the regulation of overdose reversal products, provided input on the interview guide, and participated in monthly data review meetings. The UNC research team maintained independence in data collection, analysis, and interpretation, with FDA colleagues contributing as subject matter experts and sharing perspectives relating to regulatory and public health considerations. Results Participant accounts suggested that overdose reversal, like any emergency response, is at once a predictable and an unfamiliar affair. There are common signs and symptoms, vital gear, and recommended action steps. Yet if overdose response followed a standard protocol, every reversal would unfold the same way: recognize symptoms, call 911, administer naloxone, wait. Instead, participants’ narratives revealed constant deviation from this imagined simplicity. Across interviews with 74 community members who have reversed overdoses, the collective narrative demonstrated that complexity does not simply complicate overdose response – it defines it. Our analysis identified complexity unfolding as two kinds of critical moments during overdose encounters. Inflection points are the moments where a course of action must be determined, whether by learned habit or immediate judgment (Additional File 1): How do I know this is an overdose? What kind of naloxone (if any) should I administer? Do I need to call 911? Friction points were obstacles that impeded an ideal response (Additional File 2), including unexpected reactions, bystander interference, or depleted naloxone supplies. Together, these inflection and friction structured the trajectory of the overdose reversals described by each participant, from recognition to revival. How participants recognized and responded to these critical moments reflected diverse trajectories of learning through repeated exposure to overdose events. Among the 68 participants who shared an estimate of reversals performed, most had extensive experience: only 4 reported fewer than 3 reversals and the majority ( n = 47) reported between 3–40 reversals. Five participants reported over 100 reversals. Overdose events unfolded across varied settings and relationships. Most participants described reversing significant others, friends, or neighbors, though several encountered strangers in parks, parking lots, or other public spaces. Reversals occurred in homes, friends' houses, cars, hotels, encampments, and apartment hallways. Some participants personally witnessed the overdose while using together or socializing. Others were summoned—called from another location or alerted by someone in the next room over. Still others came upon strangers, noticing people huddled around an unresponsive body on the street. Naloxone retrieval depended on circumstance: at home, participants kept it in bathroom or bedroom cabinets; in cars, in glove compartments or under seats; on the go, in purses or on keychains. Some arrived to find they had no naloxone on hand—requiring them to run home, call for backup, or proceed without. In most cases, other people who used drugs were present at the scene, though occasionally participants were the sole responder, managing the scene alone with only the unconscious person present. Reversals in public spaces often drew bystanders who ranged from helpful to obstructive. Together, these scenarios illustrate the contextual variability and uncertainty participants navigated during overdose response. The unpredictability of overdose meant that each event presented its own specific challenges and circumstances—some reversals unfold with relative ease while others involve compounding complications. The following four themes capture patterns and tensions that emerged across participants' collective experiences: Between Preparation and Adaptation; Knowledge and Tools in Precarity; Managing Bodies, Spaces, and Social Dynamics; and Dignity and Autonomy at the Edge of Death. These themes synthesize the physical, social, cognitive, and ethical tensions facing community responders – tensions that required improvisation and embodied judgment beyond what can be fully specified in formal protocols. Between Preparation and Adaptation Across participants’ accounts, overdose response unfolded through a dynamic interplay between preparation and adaptation, as responders drew on established practices while continually adjusting to the specific demands of each situation. In the space between recognizing an overdose and reaching for naloxone, some decisions flow automatically while others demand careful assessment. Years of experience create habituated responses—checking for purple lips, grabbing naloxone from the nightstand, starting chest compressions. These defaults, developed through repetition and reinforced by success, often serve responders well. Yet overdose response also presents decisions without clear answers: Is this person nodding (drug-induced drowsiness) or dying? How much naloxone for someone this size? Can I trust others to call 911? Participants navigated both territories, drawing on preparation from formal training, informal observation, and accumulated experience that provided reliable defaults for routine situations and starting points for novel ones. Each overdose event involved this interplay—some elements handled through habituated practice, others requiring fresh assessment and adaptation to unique circumstances. Responders relied less on formal protocol than their own cultivated adaptive expertise. Participants often had default approaches—rousing with a sternum rub, always using intranasal naloxone—yet described departing from these preferences based on specific circumstances. For example, some reported choosing formulation based on the perceived severity of overdose or alerting emergency services only after a certain amount of time had passed. This fluidity manifested differently across participants and even within single overdose events. The interplay between preparation and adaptation began with the fundamental question of overdose recognition itself—a determination complicated by the ambiguous boundary between someone enjoying an intense high and experiencing life-threatening respiratory depression. Participants shared personal criteria for diagnosing overdoses, typically clustered around symptoms like slowed, abnormal, or absent breathing, purple or ashen color, slowed pulse, and unresponsiveness (“Slumped over, um, they start to turn blue. But generally, the first thing is if you don't get a response,” Liam, Michigan). Breathing assessment involved multiple strategies—watching chest rise, listening for abnormal sounds like gurgling or the "death rattle," feeling for breath under the nose, or checking for mirror fogging—though participants focused on breathing quality (slow, faint, stopped) rather than quantifying rate. Still, presentation was not always unequivocal. The line between overdosing and nodding can be particularly challenging to interpret. For some, assessment had become instinctual through habituation: I guess just cause I've seen it so many times. See, I just know when I see someone actually ODing versus someone just high, nodding out. (Hannah, California) But for others, the determination requires more nuanced assessment, as Emily described when reviving older and more experienced individuals: But you also gotta know, you know, a druggie overdosing as opposed to … an old druggie that drops to the floor. They're actually getting high. That's the high they like, you know, and when they go flushed white and their lips are purple, that's their high, you know what I’m saying? If you mess them up in the middle of that, though, some of them people get, like it gets worse. (Emily, California) Emily’s distinction—between someone overdosing and enjoying an intense high—illustrates that there is not an unambiguous binary of overdose and non-overdose: the determination must often be made based on environmental and individual patterns rather than prescribed signs and symptoms. Similar navigation between preparation and adaptation appeared in decisions about naloxone administration. Most participants had developed default approaches for formulation and dosing, citing factors like ease of use, effectiveness, availability, or time to revival. Yet these defaults often served as starting points rather than fixed protocols. Several participants who typically preferred intranasal naloxone would switch to intramuscular if initial doses seemed ineffective. Others who favored intramuscular administration had developed sophisticated titration strategies—administering fractional doses in an effort to minimize precipitated withdrawal while ensuring revival, adjusting based on the size of the person overdosing or perceived overdose severity. Sammy, who estimates having reversed 30–35 overdoses, shared the complexity of choosing to begin with one or two intranasal doses: If somebody just takes one hit [of opioids], you know, sometimes they don't need as much [naloxone]. … Just depending on how long they've been gone or how much they took … Like some people snort it, some people shoot it up, and some people smoke it. And depending on how much they smoked, how they smoked it, I guess you could say, like a bong, foil, or a dabber, whether they injected it or ingested it nasally. [The initial dose of naloxone administered] just depends on how much and how long [they’ve been unconscious], I suppose, and how. (Sammy, California) Sammy's calculus—weighing route of administration, quantity consumed, and time elapsed—demonstrates the multiple variables experienced responders may consider simultaneously. The phrase 'it just depends' captures the situated nature of these decisions. This thoughtful assessment extended throughout participants’ overdose encounters. Chelsea (Michigan) described withholding 911 calls unless "I cannot feel their pulse or they're not breathing," reflecting her evaluation of when emergency services become necessary. For some, even post-reversal care involved careful consideration. Peter's decisions about deciding to tell someone they had overdosed and been given naloxone exemplify this ongoing assessment: Sometimes in certain situations, it helps to not tell the person. Because oftentimes, if you tell somebody that you brought them back, you go into this panic. You can mentally make it, depending on your usage and stuff, you got a daily habit. The precipitated withdrawal can be horrible. But mentally knowing that can make it even worse than it is. (Peter, Michigan) For experienced users facing precipitated withdrawal, Peter worried that knowing they'd overdosed could intensify their psychological distress. But for people new to opioids, he believed disclosure served as an important warning: There's been a couple times that I hadn't. … When you do somebody, or somebody's Narcaned the first time, it should be like an eye-waking experience. I need to be careful or I'm going to die. (Peter, Michigan) Peter's approach—considering the person's experience level and potential psychological response when deciding what information to share—illustrates the nuanced judgments that continue even after successful revival. Participants' accounts revealed how overdose response involved constant navigation between established approaches and situational demands. While most had developed default strategies, they regularly departed from these based on their assessment of the specific person, situation, and moment. Only a few participants shared moments of hesitation or deference to others’ judgment, typically when describing their earliest reversals: “The first, I don't know how many times, I panicked. Like, oh shit, what do we do? Am I doing this right? I'm like, can I give them more than one? Am I pushing too hard?” (Pat, Michigan). Such early uncertainties often gave way to growing assurance as experience accumulated, suggesting that confidence in overdose recognition and response developed through repetition as much as training. Through repeated exposure, participants had developed sophisticated approaches that extended beyond basic protocol—integrating multiple variables, reading individual patterns, and making real-time adjustments that reflected accumulated wisdom rather than standardized training. Knowledge and Tools in Precarity Qualitative discussions revealed that gaps in knowledge, perception, and material tools are an inherent feature of real-world overdose response, requiring responders to improvise beyond what is anticipated in formal training, instructional materials, or product guidance. Overdose response often unfolds with fundamental uncertainty. Responders operate with incomplete information about the person who overdosed, encounter unexpected symptoms and presentations, and navigate the unreliability of material resources meant to help. The precarity of overdose events requires community responders to be observant and adaptive at every step. Many participants described arriving at the scene after an overdose had already begun. For some, it was a friend in the next room over. For others it was a stranger at a gas station. These participants quickly gathered information from onlookers – how long they were out, what drugs they had taken, and anything that happened in between (“Somebody comes at the door at the place and they're like, somebody's dying on the bike trail. ‘Who is it? What happened? What's going on? … Did you give him the Narcan?’,” Kia, California). Information gathering was typically the first reaction and, in many cases, informed participants’ reversal decisions, like how much naloxone to administer or whether emergency services were urgently needed. Information was not always forthcoming, however, as others present often had an incomplete picture as well. Julia lives in a public housing community where she socializes with others who use drugs. Though she prefers ‘hard’ (i.e., crack cocaine) herself, she tries to watch out for neighbors who use opioids, even picking up naloxone and clean injecting supplies from the syringe program. Julia often spends time with elderly friends who use drugs. One friend, AJ, started acting strangely one afternoon, which Julia and others dismissed as typical behavior (“We kind of realized that his actions were changing a little bit, but we just thought, you know, AJ is AJ”). When AJ turned ashy, she knew something was wrong: I’m like, what did he take? Because we were all smoking that same hard and nobody had an issue with it. So if he's doing hard, he's doing something else, but we didn't know what it was. And then, um, the person that he was messing with told us that he was, he had started, um, messing around with heroin. (Julia, Michigan). Julia and her friends put AJ in an ice bath. She dunked his head underwater and looked for air bubbles to see if he was breathing. He wasn’t. They administered intranasal naloxone, and AJ quickly awoke – thankful, albeit shivering. Although AJ was revived, Julia's response was delayed, her experience illustrating multiple uncertainties intersecting: incomplete knowledge about who uses opioids, symptoms that initially seemed behavioral rather than medical, and the challenge of recognizing overdose in unexpected places, even amongst friends. Atypical overdose presentations appeared in many accounts. Participants described physical manifestations that belied preparation, including seizures, stiffness, and bodily fluids – chiefly, blood, mucus, and vomit. Though most participants had extensive experience reversing overdoses, these encounters were sometimes tenuous and left responders questioning the best course of action. Some participants improvised when faced with these challenges: One drew on her Girl Scout training to administer rescue breathing through the nose of a person whose jaw was locked shut. Yet for many responders, uncertainty persisted throughout the entire encounter. Linda was in line at the methadone clinic and noticed a man and woman arguing a few feet in front of her. She had seen them many times before, but this day, they left in a hurry without receiving their doses. Later, on her stop at Wal-Mart down the street, Linda saw the woman yelling in the parking lot. She assumed their argument had continued until she came closer and realized the man was unconscious in the passenger seat of their car. Linda immediately jumped into action but found herself in an unfamiliar situation: He wasn't breathing anymore at that point. She said he started making weird like gurgly noises first. … I don't know if it was mucus or if maybe he started throwing up or something like while he was passing out or what it was. But he just, he had like a bunch of liquid in like his throat and nose and everything. (Linda, Pennsylvania) Linda asked the woman if he had recently eaten – she was worried he might be choking. The woman didn’t know. Not having a complete picture worried Linda: I've never seen anybody really pass out like that. But like I said, I don't know what he was doing like up until I saw him. Like, was he coughing? Was he choking? Or did he already have a cold? … It just, I don't know if it impacted it or not. Linda administered intranasal naloxone but wondered whether the mucus would render it less effective (“I was worried that like, as soon as I did it, it was just going to like run right back out or maybe block his nasal passages more.”) She instructed the woman to begin administering CPR and readied more naloxone. The man came to briefly and fell back into unconsciousness. Linda gave the second dose, and the man woke up. She felt grateful for his survival but questions whether the second dose was necessary: “That’ll always be a wonder. You’re never going to know.” Even when information is available, perception may be compromised. Overdose encounters may be brief, but time becomes distorted in these precarious moments: “It seems like it's going on for a lifetime, you know, but come to find out he was only out for 20 minutes” (Kaylah, Michigan). Time dilation can be problematic when responders administer consecutive naloxone doses. Most participants had learned from training, package instructions, or practice to wait in between doses. But perception does not always match reality: “You just can't emphasize enough how long that two to four minutes can seem to last” (Peter, Michigan). Some participants described spacing doses over what felt like half an hour, only to discover mere minutes had passed. What happened during these agonizing intervals varied: some participants provided rescue breathing or chest compressions by default, while others continued rousing efforts like yelling, shaking, or sternum rubs. In moments like these, where a timer is unlikely at hand, responders must measure time by imperfect intuition. But this is an impractical task: “Three minutes is an eternity when you're watching somebody die,” (Jennifer, California). While gaps in knowledge and perception created one form of precarity, material tools presented another. In most cases, participants reported reliable access to supplies, thanks to steady stock at their harm reduction program or treatment clinic. Yet in some situations, scarcity proved a defining challenge: Participants described managing overdoses where naloxone and other reversal supplies were unavailable, inaccessible, or failed. Here, as with perceptual uncertainty, some responders were apt to improvise. Russell (California) shared a story of his own reversal by his wife. She had a vial of naloxone but couldn’t find the accompanying syringe – only an insulin syringe with ½ inch needle, the kind they used to inject drugs. Afraid her rig wouldn’t reach Russell’s muscle tissue, she injected naloxone into his tongue. Russell has since reversed others in the same way and shares this advice with people he meets in harm reduction circles. 1 Although Russell’s wife was able to work around her lack of supplies, naloxone scarcity and device failures created absolute constraints for others. Participants who deliberately stocked naloxone in multiple locations—their homes, cars, purses—occasionally found themselves without adequate supplies when overdoses occurred. Some discovered their nasal sprays wouldn't deploy or seemed mysteriously empty at the critical moment. Others scraped together partial doses from multiple half-empty vials, hoping the combined amount would suffice. In a few cases, respondents had to manage multiple simultaneous overdoses and decide who would receive the last remaining dose. When devices work but supplies run low, responders may still exhaust their reserves. In these moments, participants pivoted to whatever remained available—chest compressions, rescue breathing, or the fraught decision to call 911 despite potential legal consequences. Most challenging, however, were encounters where naloxone was never an option. Despite preparation and experience, participants occasionally found themselves at overdose scenes with no reversal agents—their supply was at home, in their vehicle, or temporarily depleted from recent reversals. These situations stripped responders of their primary lifesaving tool. Mikey spent many years hopping trains, meeting friends in new cities and moving every few weeks. On one segment of his journey, the unexpected happened: I was on a moving freight train and my buddy went down. … We had no Narcan and I was panicked. You know what I mean? Because we have three dogs on the fucking train and just me and him. … I stand up and my dog stands up, and we're going fucking fast. I keep everything still, hold the dogs down. … Pull him on his back and try to give him CPR, try to breathe for him. He came back though. I mean, he woke up. (Mikey, Pennsylvania) In these moments of precarity—of knowledge, perception, or materials—responders demonstrated that overdose reversal extends far beyond naloxone administration. Their accounts reveal both the idiosyncratic reality of overdoses and the persistence of responders who must routinely improvise beyond standardized guidance in order to sustain life. Managing Bodies, Spaces, and Social Dynamics It is easy to imagine overdose response in a vacuum: One person is unconscious on the ground, a second hovering over them, nasal spray in hand—a situation where knowledge and composure would seemingly suffice. In reality, reversals often unfold with complex choreography as responders manage the physical and social dynamics of the scene. Bodies are crumpled, doors are locked, bystanders are panicked or uncooperative. In these scenarios, revival becomes as much about managing a scene as saving a life. Overdoses do not always unfold in a living room or on a park bench; space is often at a premium. Participants recounted reviving people who were in a bathroom stall, wedged between a toilet and tub, or slumped over in a cramped car. In these moments, participants had to decide between rescuing in place or spending precious seconds repositioning. Sometimes there was no choice at all – the orientation of the scene prevented access to a nasal cavity for naloxone or a mouth for rescue breathing. These respondents faced the physical challenge of dragging someone out of a cramped car or maneuvering a limp body out of a small bathroom. Most troubling were scenarios where persons who overdosed were behind closed doors and responders were forced to pick a lock or break the door down. Trish wasn’t using at the time of her most recent reversal, but her boyfriend was. She remembers him going into their upstairs bathroom, his normal space to use. Two minutes later, she heard a thump. Trish ran upstairs, knocked, and didn’t receive a response. Peering under the closed door, she could see her boyfriend’s crumpled body. So I grabbed the hanger, shoved it in there, unlocked it, but then I couldn't shove him. Because he was in between the sink. His head was by the toilet and his butt and legs were by the door … I sat on the floor and shoved with both feet. And I slid him at least a little bit. (Trish, Pennsylvania) By the time Trish got the door open, her boyfriend was already cyanotic. She straightened his body, tilted his head back, and administered a dose of intranasal naloxone. He woke up enough to get down the stairs, but as soon they reached the bottom of the flight, he fell unconscious again. Trish gave a second dose, and after 10 agonizing minutes of rousing and waiting, her boyfriend finally awoke for good. The demands of overdose response extended beyond navigating spaces to handling the bodies themselves. Many participants shared stories about body shape and size presenting particular challenges. Shawn (California) sometimes turns over responsibility when the person who overdosed is a woman, typically smaller than himself, “because they’re already frail … I don’t want to break nothing.” More commonly, participants had issues with larger individuals, who may be flipped on their stomach, stuck in an awkward position, or too heavy to move. Several participants discussed the difficulty of rescue breathing in these scenarios. Erin, who estimates she reverses more than ten overdoses a month, has only ever lost one person, a close friend. When he fell unconscious, she only had one nasal spray on hand, which she argued is not as effective as intramuscular naloxone. Two minutes later, with the nasal spray proving insufficient, Erin turned to CPR, which she was forced to perform alone when the only other person present left the scene. I've got an almost 300 pound man on me. So imagine yourself doing this…pum pum pum, phoo. Wait. Pum pum pum, phoo. After about two minutes of that, you're gonna almost exhaust yourself to where you pass out. I told the guy, I said please don't leave. I'm like, dude, I can do this. All you have to do is just stay here. That motherfucker [bystander] just left. … I can almost save anybody. But I couldn't do it by myself. (Erin, California) The choreography of Erin’s response continued as she had to alternate between breathing and speaking with an unhelpful EMS dispatcher: When I called up the police they were like, why do you keep leaving the phone? … I'm fucking saving somebody here. Get somebody out here. What the fuck are you asking me that for? I gotta go. Hold on. Pum pum pum, phoo. You know what I mean? It was really hard. I've never lost anybody in my whole life. Except that one person. Erin was not unique in her experience of unsuccessfully seeking active support from others. Though some participants recounted collaborating well with others on reversals in the past – one person rescue breathing while the other fetches the naloxone, for instance – these experiences were the exception. Almost all described taking charge when others were present, trusting their own expertise and levelheadedness amidst panicked bystanders. Participants tended to feel confident in the lead, if not a little annoyed by a backdrop of crying, scrambling, and arguing. In many cases, responders encountered social dynamics that were not only distracting, but actively obstructive. Participants described needing to managing others’ emotions, asking people to leave the room, and arguing with antagonistic bystanders over the best course of action. Mikey is accustomed to pandemonium during overdoses. He finds that others usually make the scene worse, not better. As he recalls when a friend overdosed on his rinse (the residue left over in the syringe or cooker): Everyone's surrounding him, Cindy’s freaking out, trying to get him back … She went to do CPR and she didn't plug his nose and I had to, like, throw her off. And she was fighting me off. She's like, no, get the fuck – She knows that I can handle it. But, and it was fine. … Almost every time, it's crowd control. Like, you hear one person yelling, everyone's yelling, everyone comes around, like I said, arguing over who can handle it better … You just gotta not pay attention to them, just stay calm, and just get up in there and just give them mouth to mouth, you know, without permission. I don't need you to say it's okay, I'll kick you off if I need to, if you're not doing it right. (Mikey, Pennsylvania) Many participants encountered unhelpful bystanders, like one “petty” and “childish” woman who refused to hand over the naloxone to the participant because she wanted the experience of administering it herself. On the contrary, several participants found no help when they needed it. In most cases, these were bystanders who refused to call 911, typically for fear of legal repercussions. Arnold described a rare encounter where he was pushed by frustration to leave, a decision he regrets: I was asked to administer meth to a guy [by his cousin] to bring them back, but I refused. Yeah, I refused. I said, the only way I'm willing to help is if you get your shit and everybody leaves and I stay with them and call 911. That's the help I'm willing to give. Now this time I felt really bad because he refused me. So I walked out of there leaving him the way he was, and I felt really bad about that. He didn't die. (Arnold, Michigan) Though Arnold’s decision to leave was rare among participants, it illustrates how social conflict can derail overdose response: Misaligned priorities, competing assessments of risk, or breakdowns in coordination among people present can disrupt response efforts and jeopardize survival. These accounts reveal how the imagined simplicity of naloxone administration dissolves into complex negotiations with physical spaces, uncooperative bodies, and chaotic social dynamics—all while racing against time. Dignity and Autonomy at the Edge of Death The calculus of overdose response often extended beyond how best to save a life. In participant accounts, these events often presented ethical quandaries, where responders balance revival with respecting bodily autonomy and minimizing harm—including the harms of lifesaving interventions themselves. Many participants demonstrated sensitivity to the moral imperative of preserving human dignity, even in such tenuous circumstances. Some decried certain rousing tactics – like heavy-handed slaps or ice in the pants – as unnecessary and inhumane (“Don’t abuse them, man,” Erin, California). A few participants recounted briefly hesitating to reverse people in undress, recognizing the inherent intimacy of handling a nude body. A person experiencing overdose is in a state of ultimate vulnerability, unable to advocate for their needs. A particularly fraught issue was what participants called the ‘do not resuscitate order’ (DNR): Individuals who had demanded, should they fall out (i.e., appear to overdose), no attempt be made to save their lives. Participants shared that certain DNRers were despondent or lived with suicidal ideations, though others simply felt the risks were justified to avoid losing a good nod. Nearly all participants who encountered DNRers were obstinate about putting life first and facing the consequences (namely, the person waking up angry): “Nobody’s ODing on my watch … You’re gonna have to want to die some other time,” (Chrissie, California). Most persons who overdosed were ultimately grateful, though even among those who awoke upset, participants remained undeterred in their resolve: “I’ve had a few friends, they were like, beating on my chest, saying why did I bring them back? Cause I always will. If I’m around, I’m gonna do that” (William, California). For Seth, however, DNRs are more complicated. Seth knows that life can be difficult in the throes of dependence, and wonders if a person with earnest intent deserves their wishes to be respected: I mean, if I find that's what they really want, and they're in their house, their own home. Stuff like that. You know? I had a buddy, had cancer and had a bad heart and shit like that. He went out like that. … I mean, a lot of them, a lot of us, that's how they feel. If they didn't get clean, you know, and turn around, they just feel like, oh, fuck it, you know, I've been struggling and my body hurts, you know? (Seth, Pennsylvania) Unlike medical DNRs, these informal declarations carried no legal weight, yet they could present profound moral dilemmas. Of all the competing imperatives in overdose response, the specter of precipitated withdrawal most pervasively shaped participants' decisions. Most had experienced precipitated withdrawal themselves and carried visceral knowledge of the agonizing minutes and hours that can follow a revival: Disoriented wakefulness quickly gives way to sweating, chills, vomiting, diarrhea, and foreboding anxiety and craving. This embodied understanding created a specific tension: naloxone saves lives but can inflict immediate suffering on those saved. Participants navigated this tension differently. Some felt that a second chance at life justified temporary suffering and held no qualms about doing whatever it takes to complete a reversal. After all, many had themselves suffered such misery and came through on the other side. They explained how it is better to be safe than sorry: “Would you rather be sick or you’d rather be dead, bro?” (Mack, Pennsylvania). Others were extremely cautious about their approach, hesitating at each turn: How much should I use? Is a second dose necessary? How long should I wait? Should I even give naloxone at all? Linda is thankful she has never had to administer naloxone to a loved one – a situation that some participants described as carrying additional emotional weight – though she came close during her husband’s suspected overdose. In retrospect, she believes he probably needed the lifesaving medication, but explains what made her hesitate: Being afraid that I was wrong. That he didn't need it yet. … Because it sucks so bad. Like, precipitated withdrawal is the worst. And I know if you get enough Narcan, that's what it'll basically do to you. So I'm, like, trying to judge. Am I correct on this decision? … It definitely was what made me hesitate a bit. (Linda, Pennsylvania) Linda tries to wait at least five minutes before administering a second dose. “The least, the better,” she explained. Many others shared her sentiment – even in moments of panic and imminent mortality, as instinct begs one to push the plunger, the pains of withdrawal must be measured. Chelsea recalls a few occasions where she woke up from an overdose and vomited extensively. These experiences informed her own approach to reversing. Now she tries rousing, rescue breathing, and chest compressions before reaching for naloxone. I put that into perspective, how shitty I feel. I try to do everything before I try to bring them back, before I hit them with Narcan. I don’t just use it recklessly. You know? Some people are like, oh, they're nodding out. Hit them with the Narcan. … And I'm like, gosh, that's so cruel. (Chelsea, Michigan) Death is not the only hazard of overdose. Beneath the fog of sedation, control is abandoned and vulnerability laid bare. Each responder decides for themselves how the primacy of survival weighs against the dignity and autonomy of the voiceless. Discussion In this qualitative investigation, we find that overdose response is a practice that defies standardization. Protocol alone cannot resolve the social and physical demands, nor the cognitive and ethical tensions, intrinsic to saving a life within a complex and evolving landscape of drug supply and drug use patterns. Our findings reflect the experiences of 74 lay responders who have collectively performed hundreds of reversals, despite carrying the cumulative trauma of these interventions—which many described as more distressing than their own overdoses. Their stories suggest that the practice of overdose response is defined by managed uncertainty – reading an unfamiliar scene, navigating imperfect courses of action, resolving conflicting priorities. It is all the more astonishing that very few lost someone under their care. Our findings build on emerging literature documenting the complexity of overdose response decision-making. Researchers have recently identified multiple decisional challenges in community naloxone administration in the United Kingdom and New York City, including dose, timing, and repeat administration [ 15 , 20 , 21 ]. These studies suggest that overdose response involves multiple decision points where several approaches may be appropriate, requiring contingent adjustments (depending, for instance, on whether the person awakens with withdrawal symptoms, hostility, mild physical and emotional reactions, or a combination of the above) [ 21 ]. Our analysis extends these frameworks by revealing how lay responders navigate not just isolated decisions but cascading inflection and friction points that fundamentally shape each response trajectory. The complexity and urgency of revival suggests that community responders often operate through heuristics (mental short cuts) rather than systematic, deliberative reasoning [ 22 ], a pattern well-documented among EMS providers and emergency physicians facing similar time pressures and incomplete information [ 23 , 24 ]. Our findings confirm that protocol gives way to improvisation when competing pressures do not conform to expectation. The implications are significant: if responders rely on pattern recognition and situational adaptation rather than standardized steps, training that emphasizes rote memorization may be fundamentally misaligned with actual practice. Furthermore, assumptions about "proper" overdose response often ignore pragmatic realities. For example, Wetteman et al. found that people remain reluctant to call 911 despite Good Samaritan laws, doubting legal protections will be honored in practice [ 25 ]. Our participants similarly described avoiding emergency services not from ignorance but from experientially grounded skepticism about law enforcement involvement. Protocols are further complicated when they exhibit their own hidden ambiguities. For instance, Narcan package instructions state to wait 2–3 minutes between doses of naloxone, while some participants recalled learning different ranges from overdose trainings or paramedics (e.g., 3–5 minutes). Dosing interval ranges and variation across training protocols require responders to make real-time decisions about the appropriate interval for re-dosing, without clear guidance on the contextual factors on which to base these decisions. Our participants' experiences with time distortion compound this problem: If ‘three minutes is an eternity when you're watching somebody die,’ an instruction to wait 2–3 minutes becomes practically meaningless. Responders must ultimately rely on their own judgment about when 'enough' time has passed. The challenges our participants described – ambiguous symptomology, bystander management, unfavorable physical spaces, patient dignity – mirror those documented among paramedics in emergency scenarios [ 26 – 28 ]. Likewise, many adaptive practices, like pattern recognition, protocol deviation, peer learning, and reliance on intuition, are common in experienced paramedics [ 26 – 29 ]. Yet community responders navigate these complexities without the training infrastructure, continuing education, institutional resources, and legal protections available to credentialed emergency workers. Addressing this gap requires rethinking how we prepare community members for overdose response. One goal of overdose education, particularly for populations likely to witness multiple overdoses, should be to instill adaptive expertise – the ability to apply knowledge and skills to both familiar and unfamiliar cases [ 30 ]. Alternative pedagogical approaches to traditional skills-based training that acknowledge complexity rather than simplifying it, are needed. Foundational skills like naloxone administration and CPR remain essential; however, real-world response requires building on these basics. We propose three methods, each commonly used in medical training [ 31 – 33 ], to consider in introductory and continuing education on overdose reversal. First, our findings indicate there are not always clear answers to questions of naloxone administration, supportive interventions, and aftercare. Training should encourage reflective interaction with scenarios where the 'right' response depends on context. Dialogic learning, based on the Socratic method, is an approach that emphasizes dialogue, questioning, and collective meaning-making rather than rote instruction [ 31 – 34 ]. Learners engage with each other’s perspectives and experiences, co-constructing understanding and working through multiple answers to the same question. Dialogic learning may be complemented by a second pedagogical approach, problem-based learning, which presents structured but open-ended problems to solve [ 35 ] – for instance, a vignette where naloxone access is limited, bystanders are hostile, and/or the person who overdosed has expressed DNR wishes [ 36 ]. These approaches would ideally teach trainees to apply knowledge flexibly rather than only memorize fixed steps. Finally, the experiential knowledge of community responders cannot be underemphasized. Near-peer models, where trainings are co-facilitated by people who have reversed multiple overdoses, acknowledge the value of learned expertise that is not captured in protocols [ 37 ]. These approaches could enhance standardized curricula by preparing responders for the complex situations that go beyond standard protocols. We note that our participants described an array of strategies which invariably included a few that are likely ineffective and may delay critical interventions (e.g., ice baths). Any training, whether peer-facilitated or otherwise, would need to account for misconceptions as well as innovations. Participants described very few scenarios where naloxone was unavailable when needed, and these were typically overdoses that occurred away from their caches at home or in the car. Of greater concern was how to use the naloxone on hand effectively without precipitating withdrawal [ 38 ]. Many experienced responders described a preference for intramuscular naloxone, which allows dose titration—starting with smaller amounts to minimize withdrawal while ensuring revival. Evidence is lacking on fractional intramuscular dosing, though naloxone is commonly titrated to effect intravenously in hospital [ 39 ]. Still, our recent analysis of 17 years of harm reduction program data suggests withdrawal symptoms are significantly less common when naloxone is administered intramuscularly [ 3 ]. Despite these potential advantages, intranasal naloxone remains the dominant formulation in distribution programs due to its ease of use and broad acceptability [ 40 , 41 ]. Additionally, social stigma surrounding needles—including concerns about needle debris and negative associations with injection drug use and communicable disease transmission—may limit community acceptance and uptake of intramuscular formulations [ 40 , 42 ]. Taken together, these findings suggest that different naloxone products used for community administration offer distinct advantages, and that participants varied in their preferred routes of administration based on experience and context. Ensuring access to multiple community-use naloxone products may better accommodate responder needs and preferences, particularly among experienced responders. Importantly, the perspectives of people who use drugs on their preferred formulation for their own potential overdoses should also be considered, though research on these preferences remains limited. The added benefit of intramuscular naloxone's lower cost [ 43 ] makes expanded access not only clinically sound but economically advantageous, allowing programs to stretch limited budgets while honoring responder expertise and choice. The burden placed on community responders raises important ethical questions. Buchman et al. argue that expecting these populations to serve as de facto emergency responders shifts responsibility for a public health crisis onto those least resourced to manage it [ 44 ]. Yet Rochester & Graboyes found that many people who use drugs experience overdose reversal as empowering, providing purpose and community connection [ 45 ]. Our findings support both perspectives: participants demonstrated remarkable expertise while navigating extraordinary challenges with minimal support. Several participants had reversed dozens of overdoses, with some estimating over 100 reversals—experience comparable to many emergency medical professionals. Yet their life-saving work remains largely invisible, uncelebrated, and unsupported by public health infrastructure. The solution is not to shift responsibility away from community responders—who will remain the first line of defense regardless of policy—but to recognize and resource their essential role. This includes training that reflects real-world complexity, emotional support for the trauma of repeated life-or-death interventions, and public acknowledgment and celebration of their public health contributions, which are often given thanklessly and at significant personal cost. Our study has some limitations. Although overdose is undoubtedly a memorable event, accounts were retrospective and narratives may be simplified. Likewise, participants may have exhibited social desirability bias and avoided discussing unsuccessful reversals or encounters that might evoke embarrassment, shame, or perceived failure. In addition, participation was voluntary, and individuals willing to speak at length about overdose reversal may differ systematically from more hesitant or reluctant participants. Those who are uncertain, fearful, or conflicted about their actions—particularly individuals who did not intervene or who disengaged from an overdose scene—may be less inclined to share their experiences, and their perspectives are likely underrepresented in this analysis. Our study is limited to three metropolitan areas in Michigan, Pennsylvania, and California; overdose reversals may differ in other places based on local drug market composition, harm reduction access, and drug policies. Our primary recruitment sites were harm reduction programs, which likely misses perspectives from bystanders who reverse overdoses outside harm reduction networks. Many participants also reported high numbers of reversals, and as such, our findings may not reflect the experiences of those with less exposure. As with any qualitative study, the aim of this research is not generalizability but rather to capture the rich perspectives of a seldom heard group that are often missing or masked in quantitative research. Nonetheless, we note that multiple reversals was not an eligibility criterion, and the depth of experience captured in our analysis may be common, at least among people who attend harm reduction programs. One previous study defined ‘supersavers’ as those with three or more naloxone administration events [ 46 ]. Our findings suggest this is likely a conservative definition that misses the routinization of overdose over time [ 47 ]. Indeed, at this stage in its evolution, the overdose epidemic is better understood as endemic. Conclusion Our study demonstrates that overdose response defies protocol, requiring navigation of complex physical, social, and ethical challenges. The 74 participants—many with extensive experience responding to overdoses—revealed expertise developed through repeated life-and-death decisions: reading ambiguous symptoms, managing chaotic environments, and balancing survival against suffering. This embodied knowledge deserves recognition as legitimate expertise. Public health approaches must evolve beyond 'naloxone saves lives' to acknowledge the full complexity of community response, providing training that develops judgment, ensuring access to preferred formulations, and supporting those who serve as our invisible frontline against overdose mortality. Declarations Ethics approval and consent to participate: The study was approved by the University of North Carolina-Chapel Hill Institutional Review Board (#24-0265). A waiver of written informed consent for interviews was approved by the UNC IRB for participants to minimize risks associated with creating signed records of sensitive information. Verbal consent was obtained and documented by interviewers, with no signatures or identifying information collected. Consent for publication: Not applicable. Availability of data and materials: Data may be made available upon reasonable request to the corresponding author. Competing interests : The authors declare that they have no competing interests. Funding : The study was supported by the U.S. Food & Drug Administration Center for Drug Evaluation & Research under a broad agency announcement (75F40122C00193, PI Dasgupta). As part of this partnership, FDA scientists identified priority research questions pertinent to the regulation of overdose reversal products, provided input on the interview guide, and participated in monthly data review meetings. The UNC research team maintained independence in data collection, analysis, and interpretation, with FDA colleagues contributing as subject matter experts and sharing perspectives relating to regulatory and public health considerations. Authors’ contributions: ALS was responsible for conceptualization, methodology, investigation, formal analysis, writing – original draft preparation, project administration. DCC was responsible for formal analysis, writing – review & editing. EJG was responsible for conceptualization, methodology, formal analysis, writing – review & editing. JM, ZDWD, AB, MV, SA, SJ, MDS, EJW and MESM were responsible for conceptualization, resources, writing – review & editing. ND were responsible for conceptualization, funding acquisition, writing – reviewing & editing. Acknowledgements: The authors wish to acknowledge all participants for candidly sharing stories that carry trauma and loss. Disclaimer The contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the US Food and Drug Administration. References National Institute on Drug Abuse. Drug Overdose Deaths: Facts and Figures [Internet]. 2025 [cited 2024 Sept 6]. 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Addiction Treatment Forum [Internet]. 2022 Sept 27 [cited 2025 Sept 23]; Available from: https://atforum.com/2022/09/fda-harm-reduction-organizations-naloxone Buchman DZ, Orkin AM, Strike C, Upshur REG. Overdose Education and Naloxone Distribution Programmes and the Ethics of Task Shifting. Public Health Ethics. 2018 July 1;11(2):151–64. Rochester E, Graboyes M. Experiences of people who use drugs with naloxone administration: a qualitative study. Drugs: Educ Prev Policy. 2022;29(1):54–61. Eide D, Lobmaier P, Clausen T. Who is using take-home naloxone? An examination of supersavers. Harm Reduct J 2022 June 18;19(1):65. Pro G, Richoux C, Bolt M, Kincade A, White R, Kasper C, et al. Factors Associated With Self-Reported Overdose Reversals Using Naloxone in Little Rock, Arkansas: Implications for Harm Reduction Service Delivery in the US South. J Drug Issues. 2025;55(4):533–49. Footnotes Naloxone is labeled for intramuscular injection. Intralingual injection has not been studied and may introduce concerns such as bleeding and airway compromise. Additional Declarations No competing interests reported. Supplementary Files MorethanMedicineAdditionalFile1HRJ.docx Additional File 1 (.docx): Inflection points of overdose response with illustrative quotations MorethanMedicineAdditionalFile2HRJ.docx Additional File 2 (.docx): Friction points of overdose response with illustrative quotations Cite Share Download PDF Status: Under Review Version 1 posted Reviews received at journal 16 May, 2026 Reviews received at journal 01 May, 2026 Reviewers agreed at journal 29 Apr, 2026 Reviewers agreed at journal 27 Apr, 2026 Reviewers agreed at journal 27 Apr, 2026 Reviewers agreed at journal 27 Apr, 2026 Reviewers invited by journal 26 Apr, 2026 Editor assigned by journal 17 Mar, 2026 Submission checks completed at journal 17 Mar, 2026 First submitted to journal 16 Mar, 2026 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Sibley","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAu0lEQVRIiWNgGAWjYFACxjaGBwwMchAOG7FaEhgYjEnRAlQG1JLYQLQW/v7DbQ8SKg6nb7jd/IDhQ9lhwlokbiS2GyScOZy74c4xA8YZ54jQwnCDsU0isQ2o5UYOAzNvGxFa5M8fBGr5dzjdAKTlLzFaDA4kArU0HE4Aa2EkRosh2C/H0g1n3kgzONhzLp2wFrnzx589+FBjLc93I/nhgx9l1oS1QEEzmDxAtHogqCNF8SgYBaNgFIw0AACoakEnatO74QAAAABJRU5ErkJggg==","orcid":"","institution":"University of North Carolina at Chapel Hill","correspondingAuthor":true,"prefix":"","firstName":"Adams","middleName":"L.","lastName":"Sibley","suffix":""},{"id":633176700,"identity":"4fcb5d99-a013-4bb3-b5ba-be6f45ed8ee9","order_by":1,"name":"David C. Colston","email":"","orcid":"","institution":"University of North Carolina at Chapel Hill","correspondingAuthor":false,"prefix":"","firstName":"David","middleName":"C.","lastName":"Colston","suffix":""},{"id":633176701,"identity":"3f088dd9-8133-4835-a4e1-9fac5e3ccbc7","order_by":2,"name":"Elizabeth Joniak-Grant","email":"","orcid":"","institution":"University of North Carolina at Chapel Hill","correspondingAuthor":false,"prefix":"","firstName":"Elizabeth","middleName":"","lastName":"Joniak-Grant","suffix":""},{"id":633176702,"identity":"0792e899-c67e-450e-95dd-abca541aa5d4","order_by":3,"name":"Blair Coleman","email":"","orcid":"","institution":"U.S. Food and Drug Administration","correspondingAuthor":false,"prefix":"","firstName":"Blair","middleName":"","lastName":"Coleman","suffix":""},{"id":633176703,"identity":"378c634e-6bf2-4e82-af8f-d2693e41b4c9","order_by":4,"name":"Jana McAninch","email":"","orcid":"","institution":"U.S. Food and Drug Administration","correspondingAuthor":false,"prefix":"","firstName":"Jana","middleName":"","lastName":"McAninch","suffix":""},{"id":633176704,"identity":"a602f30c-9892-4f6c-9722-4d1693a03a88","order_by":5,"name":"Zachary D.W. Dezman","email":"","orcid":"","institution":"U.S. Food and Drug Administration","correspondingAuthor":false,"prefix":"","firstName":"Zachary","middleName":"D.W.","lastName":"Dezman","suffix":""},{"id":633176705,"identity":"2dbec414-606a-4d6a-a675-cf25fe27b284","order_by":6,"name":"Alice Bell","email":"","orcid":"","institution":"Prevention Point Pittsburgh","correspondingAuthor":false,"prefix":"","firstName":"Alice","middleName":"","lastName":"Bell","suffix":""},{"id":633176706,"identity":"cfa60be9-ab56-4d84-a7e9-42366b149a53","order_by":7,"name":"Malcolm Visnich","email":"","orcid":"","institution":"Prevention Point Pittsburgh","correspondingAuthor":false,"prefix":"","firstName":"Malcolm","middleName":"","lastName":"Visnich","suffix":""},{"id":633176707,"identity":"a9240028-be0f-432e-b931-17a39181d0a1","order_by":8,"name":"Steve Alsum","email":"","orcid":"","institution":"Grand Rapids Red Project","correspondingAuthor":false,"prefix":"","firstName":"Steve","middleName":"","lastName":"Alsum","suffix":""},{"id":633176708,"identity":"8af5a2f8-dd92-433e-9c9a-e4bf2e50e833","order_by":9,"name":"Shilo Jama","email":"","orcid":"","institution":"SANE (Safer Alternatives thru Networking and Education)","correspondingAuthor":false,"prefix":"","firstName":"Shilo","middleName":"","lastName":"Jama","suffix":""},{"id":633176709,"identity":"a910f1b6-4408-4d8d-af91-5e30bcccfbd8","order_by":10,"name":"Maya Doe-Simkins","email":"","orcid":"","institution":"Remedy Alliance for the People","correspondingAuthor":false,"prefix":"","firstName":"Maya","middleName":"","lastName":"Doe-Simkins","suffix":""},{"id":633176710,"identity":"32157b69-9357-4b14-aa04-3d95d36cd7ed","order_by":11,"name":"Eliza J. Wheeler","email":"","orcid":"","institution":"Remedy Alliance for the People","correspondingAuthor":false,"prefix":"","firstName":"Eliza","middleName":"J.","lastName":"Wheeler","suffix":""},{"id":633176711,"identity":"fdcde528-29b0-4174-9433-661a8404cc52","order_by":12,"name":"Nabarun Dasgupta","email":"","orcid":"","institution":"University of North Carolina at Chapel Hill","correspondingAuthor":false,"prefix":"","firstName":"Nabarun","middleName":"","lastName":"Dasgupta","suffix":""}],"badges":[],"createdAt":"2026-03-16 18:08:50","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9140958/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9140958/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":108805044,"identity":"a0c263d1-c83f-4e36-a43c-d26acaaeff9f","added_by":"auto","created_at":"2026-05-08 15:24:37","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":315659,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9140958/v1/13edad0f-178b-47f1-ae1b-09714457fbba.pdf"},{"id":108557888,"identity":"dff138b6-15f1-48db-83be-292fa63dc9b1","added_by":"auto","created_at":"2026-05-06 02:06:54","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":56488,"visible":true,"origin":"","legend":"\u003cp\u003eAdditional File 1 (.docx): Inflection points of overdose response with illustrative quotations\u003c/p\u003e","description":"","filename":"MorethanMedicineAdditionalFile1HRJ.docx","url":"https://assets-eu.researchsquare.com/files/rs-9140958/v1/f579c183c9296404900be982.docx"},{"id":108557889,"identity":"bb42a45a-1369-4696-bc6a-6efc29eab320","added_by":"auto","created_at":"2026-05-06 02:06:54","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":42212,"visible":true,"origin":"","legend":"\u003cp\u003eAdditional File 2 (.docx): Friction points of overdose response with illustrative quotations\u003c/p\u003e","description":"","filename":"MorethanMedicineAdditionalFile2HRJ.docx","url":"https://assets-eu.researchsquare.com/files/rs-9140958/v1/9ffd22e16b5ad04e2dac2558.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"More than Medicine: The Complex Choreography of Community Overdose Response","fulltext":[{"header":"Introduction","content":"\u003cp\u003eIn 2023, 76% of the more than 100,000 overdose deaths in the United States involved opioids, primarily illicitly manufactured fentanyl [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. The mu-opioid receptor antagonist naloxone is a safe and effective medication used to reverse opioid overdose [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Available to medical professionals since 1971, naloxone has been distributed by harm reduction activists in community settings since at least the 1990s [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Take-home naloxone programs became a model for overdose prevention by the mid-2000s, though with little governmental support at that time [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Much of the early and ongoing success of these programs was due to the efforts of non-profit \u0026ldquo;naloxone buying clubs\u0026rdquo; that have bulk-ordered millions of doses of naloxone to distribute at low or no cost to partner programs. Over the last decade, state and federal policies have recognized these crucial efforts and prioritized naloxone saturation strategies to ensure the life-saving medication is available wherever and whenever it is needed [\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e]. Overdose education and naloxone distribution has likely played a crucial role in the recent downturn in overdose mortality nationally [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eThe overdose crisis is fundamentally a community-managed public health emergency, though the true scope of community overdose response remains vastly underestimated. Emergency medical service (EMS) data suggest that only 3.4% of EMS activations feature lay responder-administered naloxone [\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. However, these data fail to capture the many reversals where 911 is never called. A recent cohort study in San Francisco and Boston found that EMS was activated in fewer than half of overdoses, while retrospective data from a Pittsburgh syringe service program documented that 92% of participant-reported reversals were conducted without EMS involvement [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eOne online panel survey found that 60% of people with opioid dependence report carrying naloxone at least occasionally, compared to 10% of the general population [\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e], indicating that those closest to risk have become de facto first responders. This community preparedness represents a remarkable public health achievement: people who use drugs and their networks have created an informal emergency response system operating largely outside of the medical infrastructure.\u003c/p\u003e \u003cp\u003eYet this community-led response system remains poorly understood by public health institutions, despite its role as the first line of defense in the chain of overdose survival [\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e]. Training protocols for bystanders, disseminated through overdose education and naloxone distribution initiatives, assume standardized conditions, including unambiguous symptoms, an orderly environment, and ready access to supplies. These protocols outline a linear sequence of actions\u0026mdash;positioning the individual, administering a full dose intramuscularly or intranasally, calling 911, and waiting while providing CPR if able [\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e]. Such guidance reflects an idealized representation of overdose response. In practice, community responders face fundamentally different realities marked by panic, distractions, and multiple decision cascades [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e]. They navigate these challenges without formal medical training, often while using drugs themselves, and nevertheless successfully reverse overdoses that are not captured in official surveillance systems.\u003c/p\u003e \u003cp\u003eUnderstanding how community members successfully manage overdose events is essential for effective public health response. This qualitative study examines the experiences of 74 community members who have reversed overdoses in Pennsylvania, Michigan, and California, revealing the complex physical, psychosocial, cognitive, and ethical challenges they navigate. Their accounts demonstrate that overdose response defies standardization, requiring embodied knowledge that cannot be taught through protocols alone. Recognizing and integrating this community expertise is crucial for developing realistic training programs for lay responders, informing distribution strategies, and ultimately reducing overdose mortality.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData Collection\u003c/h2\u003e \u003cp\u003eData were collected as part of a multi-modal investigation of layperson naloxone administration, which included longitudinal analyses of overdose reversal trends using historical survey data from an established syringe service program [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e] in addition to the in-depth interviews presented in this manuscript.\u003c/p\u003e \u003cp\u003eParticipants (\u003cem\u003eN\u003c/em\u003e\u0026thinsp;=\u0026thinsp;74) in this qualitative study were a convenience sample recruited from harm reduction programs or by peer referral in western Pennsylvania (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;27), western Michigan (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;25), and central California (\u003cem\u003en\u0026thinsp;=\u003c/em\u003e\u0026thinsp;22). Inclusion criteria were: 1) aged 18 years or older, 2) administered naloxone in past 12 months, and 3) currently using drugs with overdose risk or have social contacts who use drugs with overdose risk (\u0026ldquo;Do you or the people you hang out with use drugs that could cause overdose?\u0026rdquo;). Prospective participants self-selected into the third category based on their own interpretation of \u0026ldquo;drugs that could cause overdose\u0026rdquo; and/or \u0026ldquo;the people you hang out with.\u0026rdquo;\u003c/p\u003e \u003cp\u003eThe three partner programs assisted in identifying potential participants. All three programs ask clients requesting naloxone if they have recently reversed an overdose as part of routine program operations. These clients were informed of a research opportunity, and if they expressed interest, were introduced to a study team member to learn more. Prospective participants were screened on-site and offered to participate immediately or schedule for a later date. MI and CA participants were all screened and interviewed in a private office at the program\u0026rsquo;s brick-and-mortar location. PA participants were recruited from the program\u0026rsquo;s brick-and-mortar location or one of three mobile sites. PA interviews were conducted in the program office or in private areas adjacent to the mobile locations (e.g., cars, library meeting rooms).\u003c/p\u003e \u003cp\u003eSemi-structured in-depth interviews were conducted between October 2024-March 2025 by the first author and a trained research assistant with lived experience of substance use. Topics in the interview guide included: local changes in the drug supply, harm reduction attitudes and behaviors, preferences and recommendations for different overdose reversal agents and formulations, and experiences reversing overdoses. All participants were asked to walk through a recent, memorable overdose reversal from beginning (\u0026ldquo;Can you walk me through what was going on that day?\u0026rdquo;) to end (\u0026ldquo;What happened to [person] after this overdose?\u0026rdquo;), including details about overdose identification, naloxone administration, supportive interventions (e.g., rescue breathing), and post-overdose events (e.g., after care, disposition to emergency medical services). Participants were also asked about general reversal experiences (e.g., \u0026ldquo;Has there ever been a time when someone was overdosing and things didn\u0026rsquo;t go well? What happened?\u0026rdquo;). Additionally, those who had reversed multiple overdoses were asked to share information about changes in their experiences over time. Community advisory board members from the PA site (all with lived or living experience of substance use) reviewed the interview guide and provided suggestions on question wording and additional probes.\u003c/p\u003e \u003cp\u003eInterviews averaged 45 minutes and were incentivized with \u003cspan\u003e$\u003c/span\u003e50 cash. All interviews were audio-recorded and transcribed with the \u003cem\u003ewhisper\u003c/em\u003e package in Python 3.9 then manually corrected by study team members.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eAnalytic Approach\u003c/h3\u003e\n\u003cp\u003eWe conducted a reflexive thematic analysis [\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e] informed by the Critical Decision Method (CDM) [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e]. CDM is a knowledge elicitation and analytic method for understanding decision-making in complex environments. The method has previously been used to explore proficiency in high-pressure professions, e.g., firefighting, battlefield command, and emergency medical response [\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e]. Importantly, CDM emphasizes that perceptual and contextual learning are critical complements to factual knowledge in developing expertise [\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e].\u003c/p\u003e \u003cp\u003eAnalysis employed a mixed inductive-deductive approach, with deductive codes situating our analysis around recognized steps in overdose response while remaining open to emergent patterns in participants' accounts.\u003c/p\u003e\n\u003ch3\u003eAnalytic Process\u003c/h3\u003e\n\u003cp\u003eALS transcribed interviews, during which he engaged in initial familiarization through memoing. Our analysis involved an iterative, recursive process moving between data familiarization, coding, and theme development.\u003c/p\u003e \u003cp\u003eWe began with open coding of four transcripts by two research team members (ALS and DCC), working independently to identify patterns relevant to overdose response decisions and experiences. Through discussion of these initial codes, we developed a flexible coding framework that combined:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eDeductive organizational codes structured around major overdose response steps (e.g., overdose identification, naloxone administration);\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eSub-codes informed by Critical Decision Method to capture decisional cues and contextual constraints;\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eInductive codes arising from close engagement with participants' accounts.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThis framework served as a sensitizing tool, evolving iteratively throughout analysis as we refined codes to better capture meaning and incorporated new interpretations of the data.\u003c/p\u003e \u003cp\u003eThe coding process involved initial double-coding of three transcripts with discussion after each to develop shared understanding of code application, followed by independent coding of remaining transcripts (ALS and DCC). Throughout coding, ALS developed preliminary patterns of meaning and engaged the full research team in three reflexive discussions about emerging insights, ultimately focusing our analytic lens on the tensions between protocol and practice in real-world overdose response.\u003c/p\u003e\n\u003ch3\u003eTheme Development\u003c/h3\u003e\n\u003cp\u003eFollowing coding, ALS collated coded excerpts and engaged in intensive memoing to identify patterns of shared meaning across the dataset. Initial theme development focused on inflection points and decision cues in overdose reversals. Through recursive engagement with the data\u0026mdash;returning to full transcripts, coded excerpts, and memos\u0026mdash;themes were refined to capture the precarity and situated complexity of overdose response. All coding and analysis were conducted in NVivo 1.7.2.\u003c/p\u003e\n\u003ch3\u003eReflexivity\u003c/h3\u003e\n\u003cp\u003eAuthors include researchers in an academic harm reduction lab (ALS, DCC, EJG, ND), harm reduction practitioners (AB, MV, SA, SJ, MDS, EJW) and FDA staff (BC, JM, ZDWD). This team carries diverse perspectives and extensive experience in harm reduction research and practice, emergency medicine, and qualitative health research. By bringing together stakeholders from multiple backgrounds, the conduct of this research balanced the practical aim of informing overdose policy and practice and the theoretical aim of capturing the embodied experiences and expertise of lay overdose responders. The group met monthly to discuss how the conduct of the research might impact the data collected, and how the data collected might inform analysis. This balance was especially evident in the epistemological and analytical treatment of our findings and interpretation. On the one hand (post-positivist), overdose response is understood as a series of discrete, sequential steps that can be captured through systematic inquiry. On the other (interpretivist), these experiences are inherently situated and contingent, and overdose response cannot be fully explained as a rational process. Our Results and Discussion attempt to honor each of these perspectives and aims.\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eEthical Considerations\u003c/h2\u003e \u003cp\u003eThe study was approved by the University of North Carolina-Chapel Hill Institutional Review Board (#24\u0026ndash;0265) and received a Paperwork Reduction Act waiver under the Department of Health \u0026amp; Human Services\u0026rsquo; declared Public Health Emergency regarding the opioid crisis allowing the collection of personal health information with HHS review and approval, without requiring additional approval by the Office of Management and Budget. A waiver of written informed consent for interviews was approved by the UNC IRB for participants to minimize risks associated with creating signed records of sensitive information. Verbal consent was obtained and documented by interviewers, with no signatures or identifying information collected. Demographic data are not presented as a result. Pseudonyms are used throughout this manuscript.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eRole of Funder\u003c/h3\u003e\n\u003cp\u003eThe study was supported by the U.S. Food \u0026amp; Drug Administration Center for Drug Evaluation \u0026amp; Research under a broad agency announcement (75F40122C00193, PI Dasgupta). As part of this partnership, FDA scientists identified priority research questions pertinent to the regulation of overdose reversal products, provided input on the interview guide, and participated in monthly data review meetings. The UNC research team maintained independence in data collection, analysis, and interpretation, with FDA colleagues contributing as subject matter experts and sharing perspectives relating to regulatory and public health considerations.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eParticipant accounts suggested that overdose reversal, like any emergency response, is at once a predictable and an unfamiliar affair. There are common signs and symptoms, vital gear, and recommended action steps. Yet if overdose response followed a standard protocol, every reversal would unfold the same way: recognize symptoms, call 911, administer naloxone, wait. Instead, participants\u0026rsquo; narratives revealed constant deviation from this imagined simplicity. Across interviews with 74 community members who have reversed overdoses, the collective narrative demonstrated that complexity does not simply complicate overdose response \u0026ndash; it defines it.\u003c/p\u003e \u003cp\u003eOur analysis identified complexity unfolding as two kinds of critical moments during overdose encounters. \u003cem\u003eInflection points\u003c/em\u003e are the moments where a course of action must be determined, whether by learned habit or immediate judgment (Additional File 1): How do I know this is an overdose? What kind of naloxone (if any) should I administer? Do I need to call 911? \u003cem\u003eFriction points\u003c/em\u003e were obstacles that impeded an ideal response (Additional File 2), including unexpected reactions, bystander interference, or depleted naloxone supplies. Together, these inflection and friction structured the trajectory of the overdose reversals described by each participant, from recognition to revival.\u003c/p\u003e \u003cp\u003eHow participants recognized and responded to these critical moments reflected diverse trajectories of learning through repeated exposure to overdose events. Among the 68 participants who shared an estimate of reversals performed, most had extensive experience: only 4 reported fewer than 3 reversals and the majority (\u003cem\u003en\u003c/em\u003e\u0026thinsp;=\u0026thinsp;47) reported between 3\u0026ndash;40 reversals. Five participants reported over 100 reversals.\u003c/p\u003e \u003cp\u003eOverdose events unfolded across varied settings and relationships. Most participants described reversing significant others, friends, or neighbors, though several encountered strangers in parks, parking lots, or other public spaces. Reversals occurred in homes, friends' houses, cars, hotels, encampments, and apartment hallways. Some participants personally witnessed the overdose while using together or socializing. Others were summoned\u0026mdash;called from another location or alerted by someone in the next room over. Still others came upon strangers, noticing people huddled around an unresponsive body on the street. Naloxone retrieval depended on circumstance: at home, participants kept it in bathroom or bedroom cabinets; in cars, in glove compartments or under seats; on the go, in purses or on keychains. Some arrived to find they had no naloxone on hand\u0026mdash;requiring them to run home, call for backup, or proceed without. In most cases, other people who used drugs were present at the scene, though occasionally participants were the sole responder, managing the scene alone with only the unconscious person present. Reversals in public spaces often drew bystanders who ranged from helpful to obstructive. Together, these scenarios illustrate the contextual variability and uncertainty participants navigated during overdose response.\u003c/p\u003e \u003cp\u003eThe unpredictability of overdose meant that each event presented its own specific challenges and circumstances\u0026mdash;some reversals unfold with relative ease while others involve compounding complications. The following four themes capture patterns and tensions that emerged across participants' collective experiences: \u003cem\u003eBetween Preparation and Adaptation; Knowledge and Tools in Precarity; Managing Bodies, Spaces, and Social Dynamics;\u003c/em\u003e and \u003cem\u003eDignity and Autonomy at the Edge of Death.\u003c/em\u003e These themes synthesize the physical, social, cognitive, and ethical tensions facing community responders \u0026ndash; tensions that required improvisation and embodied judgment beyond what can be fully specified in formal protocols.\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003e \u003cb\u003eBetween Preparation and Adaptation\u003c/b\u003e \u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eAcross participants\u0026rsquo; accounts, overdose response unfolded through a dynamic interplay between preparation and adaptation, as responders drew on established practices while continually adjusting to the specific demands of each situation.\u003c/p\u003e \u003cp\u003eIn the space between recognizing an overdose and reaching for naloxone, some decisions flow automatically while others demand careful assessment. Years of experience create habituated responses\u0026mdash;checking for purple lips, grabbing naloxone from the nightstand, starting chest compressions. These defaults, developed through repetition and reinforced by success, often serve responders well. Yet overdose response also presents decisions without clear answers: Is this person nodding (drug-induced drowsiness) or dying? How much naloxone for someone this size? Can I trust others to call 911? Participants navigated both territories, drawing on preparation from formal training, informal observation, and accumulated experience that provided reliable defaults for routine situations and starting points for novel ones. Each overdose event involved this interplay\u0026mdash;some elements handled through habituated practice, others requiring fresh assessment and adaptation to unique circumstances. Responders relied less on formal protocol than their own cultivated adaptive expertise.\u003c/p\u003e \u003cp\u003eParticipants often had default approaches\u0026mdash;rousing with a sternum rub, always using intranasal naloxone\u0026mdash;yet described departing from these preferences based on specific circumstances. For example, some reported choosing formulation based on the perceived severity of overdose or alerting emergency services only after a certain amount of time had passed. This fluidity manifested differently across participants and even within single overdose events.\u003c/p\u003e \u003cp\u003eThe interplay between preparation and adaptation began with the fundamental question of overdose recognition itself\u0026mdash;a determination complicated by the ambiguous boundary between someone enjoying an intense high and experiencing life-threatening respiratory depression. Participants shared personal criteria for diagnosing overdoses, typically clustered around symptoms like slowed, abnormal, or absent breathing, purple or ashen color, slowed pulse, and unresponsiveness (\u0026ldquo;Slumped over, um, they start to turn blue. But generally, the first thing is if you don't get a response,\u0026rdquo; Liam, Michigan). Breathing assessment involved multiple strategies\u0026mdash;watching chest rise, listening for abnormal sounds like gurgling or the \"death rattle,\" feeling for breath under the nose, or checking for mirror fogging\u0026mdash;though participants focused on breathing quality (slow, faint, stopped) rather than quantifying rate.\u003c/p\u003e \u003cp\u003eStill, presentation was not always unequivocal. The line between overdosing and nodding can be particularly challenging to interpret. For some, assessment had become instinctual through habituation:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI guess just cause I've seen it so many times. See, I just know when I see someone actually ODing versus someone just high, nodding out. (Hannah, California)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eBut for others, the determination requires more nuanced assessment, as Emily described when reviving older and more experienced individuals:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eBut you also gotta know, you know, a druggie overdosing as opposed to \u0026hellip; an old druggie that drops to the floor. They're actually getting high. That's the high they like, you know, and when they go flushed white and their lips are purple, that's their high, you know what I\u0026rsquo;m saying? If you mess them up in the middle of that, though, some of them people get, like it gets worse. (Emily, California)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eEmily\u0026rsquo;s distinction\u0026mdash;between someone overdosing and enjoying an intense high\u0026mdash;illustrates that there is not an unambiguous binary of overdose and non-overdose: the determination must often be made based on environmental and individual patterns rather than prescribed signs and symptoms. Similar navigation between preparation and adaptation appeared in decisions about naloxone administration. Most participants had developed default approaches for formulation and dosing, citing factors like ease of use, effectiveness, availability, or time to revival. Yet these defaults often served as starting points rather than fixed protocols. Several participants who typically preferred intranasal naloxone would switch to intramuscular if initial doses seemed ineffective. Others who favored intramuscular administration had developed sophisticated titration strategies\u0026mdash;administering fractional doses in an effort to minimize precipitated withdrawal while ensuring revival, adjusting based on the size of the person overdosing or perceived overdose severity.\u003c/p\u003e \u003cp\u003eSammy, who estimates having reversed 30\u0026ndash;35 overdoses, shared the complexity of choosing to begin with one or two intranasal doses:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eIf somebody just takes one hit [of opioids], you know, sometimes they don't need as much [naloxone]. \u0026hellip; Just depending on how long they've been gone or how much they took \u0026hellip; Like some people snort it, some people shoot it up, and some people smoke it. And depending on how much they smoked, how they smoked it, I guess you could say, like a bong, foil, or a dabber, whether they injected it or ingested it nasally. [The initial dose of naloxone administered] just depends on how much and how long [they\u0026rsquo;ve been unconscious], I suppose, and how. (Sammy, California)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eSammy's calculus\u0026mdash;weighing route of administration, quantity consumed, and time elapsed\u0026mdash;demonstrates the multiple variables experienced responders may consider simultaneously. The phrase 'it just depends' captures the situated nature of these decisions.\u003c/p\u003e \u003cp\u003eThis thoughtful assessment extended throughout participants\u0026rsquo; overdose encounters. Chelsea (Michigan) described withholding 911 calls unless \"I cannot feel their pulse or they're not breathing,\" reflecting her evaluation of when emergency services become necessary. For some, even post-reversal care involved careful consideration. Peter's decisions about deciding to tell someone they had overdosed and been given naloxone exemplify this ongoing assessment:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSometimes in certain situations, it helps to not tell the person. Because oftentimes, if you tell somebody that you brought them back, you go into this panic. You can mentally make it, depending on your usage and stuff, you got a daily habit. The precipitated withdrawal can be horrible. But mentally knowing that can make it even worse than it is. (Peter, Michigan)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eFor experienced users facing precipitated withdrawal, Peter worried that knowing they'd overdosed could intensify their psychological distress. But for people new to opioids, he believed disclosure served as an important warning:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eThere's been a couple times that I hadn't. \u0026hellip; When you do somebody, or somebody's Narcaned the first time, it should be like an eye-waking experience. I need to be careful or I'm going to die. (Peter, Michigan)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003ePeter's approach\u0026mdash;considering the person's experience level and potential psychological response when deciding what information to share\u0026mdash;illustrates the nuanced judgments that continue even after successful revival.\u003c/p\u003e \u003cp\u003eParticipants' accounts revealed how overdose response involved constant navigation between established approaches and situational demands. While most had developed default strategies, they regularly departed from these based on their assessment of the specific person, situation, and moment. Only a few participants shared moments of hesitation or deference to others\u0026rsquo; judgment, typically when describing their earliest reversals: \u0026ldquo;The first, I don't know how many times, I panicked. Like, oh shit, what do we do? Am I doing this right? I'm like, can I give them more than one? Am I pushing too hard?\u0026rdquo; (Pat, Michigan). Such early uncertainties often gave way to growing assurance as experience accumulated, suggesting that confidence in overdose recognition and response developed through repetition as much as training. Through repeated exposure, participants had developed sophisticated approaches that extended beyond basic protocol\u0026mdash;integrating multiple variables, reading individual patterns, and making real-time adjustments that reflected accumulated wisdom rather than standardized training.\u003c/p\u003e \u003cdiv id=\"Sec11\" class=\"Section2\"\u003e \u003ch2\u003eKnowledge and Tools in Precarity\u003c/h2\u003e \u003cp\u003eQualitative discussions revealed that gaps in knowledge, perception, and material tools are an inherent feature of real-world overdose response, requiring responders to improvise beyond what is anticipated in formal training, instructional materials, or product guidance.\u003c/p\u003e \u003cp\u003eOverdose response often unfolds with fundamental uncertainty. Responders operate with incomplete information about the person who overdosed, encounter unexpected symptoms and presentations, and navigate the unreliability of material resources meant to help. The precarity of overdose events requires community responders to be observant and adaptive at every step.\u003c/p\u003e \u003cp\u003eMany participants described arriving at the scene after an overdose had already begun. For some, it was a friend in the next room over. For others it was a stranger at a gas station. These participants quickly gathered information from onlookers \u0026ndash; how long they were out, what drugs they had taken, and anything that happened in between (\u0026ldquo;Somebody comes at the door at the place and they're like, somebody's dying on the bike trail. \u0026lsquo;Who is it? What happened? What's going on? \u0026hellip; Did you give him the Narcan?\u0026rsquo;,\u0026rdquo; Kia, California). Information gathering was typically the first reaction and, in many cases, informed participants\u0026rsquo; reversal decisions, like how much naloxone to administer or whether emergency services were urgently needed. Information was not always forthcoming, however, as others present often had an incomplete picture as well.\u003c/p\u003e \u003cp\u003eJulia lives in a public housing community where she socializes with others who use drugs. Though she prefers \u0026lsquo;hard\u0026rsquo; (i.e., crack cocaine) herself, she tries to watch out for neighbors who use opioids, even picking up naloxone and clean injecting supplies from the syringe program. Julia often spends time with elderly friends who use drugs. One friend, AJ, started acting strangely one afternoon, which Julia and others dismissed as typical behavior (\u0026ldquo;We kind of realized that his actions were changing a little bit, but we just thought, you know, AJ is AJ\u0026rdquo;). When AJ turned ashy, she knew something was wrong:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI\u0026rsquo;m like, what did he take? Because we were all smoking that same hard and nobody had an issue with it. So if he's doing hard, he's doing something else, but we didn't know what it was. And then, um, the person that he was messing with told us that he was, he had started, um, messing around with heroin. (Julia, Michigan).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eJulia and her friends put AJ in an ice bath. She dunked his head underwater and looked for air bubbles to see if he was breathing. He wasn\u0026rsquo;t. They administered intranasal naloxone, and AJ quickly awoke \u0026ndash; thankful, albeit shivering. Although AJ was revived, Julia's response was delayed, her experience illustrating multiple uncertainties intersecting: incomplete knowledge about who uses opioids, symptoms that initially seemed behavioral rather than medical, and the challenge of recognizing overdose in unexpected places, even amongst friends.\u003c/p\u003e \u003cp\u003eAtypical overdose presentations appeared in many accounts. Participants described physical manifestations that belied preparation, including seizures, stiffness, and bodily fluids \u0026ndash; chiefly, blood, mucus, and vomit. Though most participants had extensive experience reversing overdoses, these encounters were sometimes tenuous and left responders questioning the best course of action. Some participants improvised when faced with these challenges: One drew on her Girl Scout training to administer rescue breathing through the nose of a person whose jaw was locked shut.\u003c/p\u003e \u003cp\u003eYet for many responders, uncertainty persisted throughout the entire encounter. Linda was in line at the methadone clinic and noticed a man and woman arguing a few feet in front of her. She had seen them many times before, but this day, they left in a hurry without receiving their doses. Later, on her stop at Wal-Mart down the street, Linda saw the woman yelling in the parking lot. She assumed their argument had continued until she came closer and realized the man was unconscious in the passenger seat of their car. Linda immediately jumped into action but found herself in an unfamiliar situation:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eHe wasn't breathing anymore at that point. She said he started making weird like gurgly noises first. \u0026hellip; I don't know if it was mucus or if maybe he started throwing up or something like while he was passing out or what it was. But he just, he had like a bunch of liquid in like his throat and nose and everything. (Linda, Pennsylvania)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eLinda asked the woman if he had recently eaten \u0026ndash; she was worried he might be choking. The woman didn\u0026rsquo;t know. Not having a complete picture worried Linda:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI've never seen anybody really pass out like that. But like I said, I don't know what he was doing like up until I saw him. Like, was he coughing? Was he choking? Or did he already have a cold? \u0026hellip; It just, I don't know if it impacted it or not.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eLinda administered intranasal naloxone but wondered whether the mucus would render it less effective (\u0026ldquo;I was worried that like, as soon as I did it, it was just going to like run right back out or maybe block his nasal passages more.\u0026rdquo;) She instructed the woman to begin administering CPR and readied more naloxone. The man came to briefly and fell back into unconsciousness. Linda gave the second dose, and the man woke up. She felt grateful for his survival but questions whether the second dose was necessary: \u0026ldquo;That\u0026rsquo;ll always be a wonder. You\u0026rsquo;re never going to know.\u0026rdquo;\u003c/p\u003e \u003cp\u003eEven when information is available, perception may be compromised. Overdose encounters may be brief, but time becomes distorted in these precarious moments: \u0026ldquo;It seems like it's going on for a lifetime, you know, but come to find out he was only out for 20 minutes\u0026rdquo; (Kaylah, Michigan). Time dilation can be problematic when responders administer consecutive naloxone doses. Most participants had learned from training, package instructions, or practice to wait in between doses. But perception does not always match reality: \u0026ldquo;You just can't emphasize enough how long that two to four minutes can seem to last\u0026rdquo; (Peter, Michigan). Some participants described spacing doses over what felt like half an hour, only to discover mere minutes had passed. What happened during these agonizing intervals varied: some participants provided rescue breathing or chest compressions by default, while others continued rousing efforts like yelling, shaking, or sternum rubs. In moments like these, where a timer is unlikely at hand, responders must measure time by imperfect intuition. But this is an impractical task: \u0026ldquo;Three minutes is an eternity when you're watching somebody die,\u0026rdquo; (Jennifer, California).\u003c/p\u003e \u003cp\u003eWhile gaps in knowledge and perception created one form of precarity, material tools presented another. In most cases, participants reported reliable access to supplies, thanks to steady stock at their harm reduction program or treatment clinic. Yet in some situations, scarcity proved a defining challenge: Participants described managing overdoses where naloxone and other reversal supplies were unavailable, inaccessible, or failed. Here, as with perceptual uncertainty, some responders were apt to improvise. Russell (California) shared a story of his own reversal by his wife. She had a vial of naloxone but couldn\u0026rsquo;t find the accompanying syringe \u0026ndash; only an insulin syringe with \u0026frac12; inch needle, the kind they used to inject drugs. Afraid her rig wouldn\u0026rsquo;t reach Russell\u0026rsquo;s muscle tissue, she injected naloxone into his tongue. Russell has since reversed others in the same way and shares this advice with people he meets in harm reduction circles.\u003csup\u003e1\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eAlthough Russell\u0026rsquo;s wife was able to work around her lack of supplies, naloxone scarcity and device failures created absolute constraints for others. Participants who deliberately stocked naloxone in multiple locations\u0026mdash;their homes, cars, purses\u0026mdash;occasionally found themselves without adequate supplies when overdoses occurred. Some discovered their nasal sprays wouldn't deploy or seemed mysteriously empty at the critical moment. Others scraped together partial doses from multiple half-empty vials, hoping the combined amount would suffice. In a few cases, respondents had to manage multiple simultaneous overdoses and decide who would receive the last remaining dose.\u003c/p\u003e \u003cp\u003eWhen devices work but supplies run low, responders may still exhaust their reserves. In these moments, participants pivoted to whatever remained available\u0026mdash;chest compressions, rescue breathing, or the fraught decision to call 911 despite potential legal consequences. Most challenging, however, were encounters where naloxone was never an option. Despite preparation and experience, participants occasionally found themselves at overdose scenes with no reversal agents\u0026mdash;their supply was at home, in their vehicle, or temporarily depleted from recent reversals. These situations stripped responders of their primary lifesaving tool.\u003c/p\u003e \u003cp\u003eMikey spent many years hopping trains, meeting friends in new cities and moving every few weeks. On one segment of his journey, the unexpected happened:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI was on a moving freight train and my buddy went down. \u0026hellip; We had no Narcan and I was panicked. You know what I mean? Because we have three dogs on the fucking train and just me and him. \u0026hellip; I stand up and my dog stands up, and we're going fucking fast. I keep everything still, hold the dogs down. \u0026hellip; Pull him on his back and try to give him CPR, try to breathe for him. He came back though. I mean, he woke up. (Mikey, Pennsylvania)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eIn these moments of precarity\u0026mdash;of knowledge, perception, or materials\u0026mdash;responders demonstrated that overdose reversal extends far beyond naloxone administration. Their accounts reveal both the idiosyncratic reality of overdoses and the persistence of responders who must routinely improvise beyond standardized guidance in order to sustain life.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec12\" class=\"Section2\"\u003e \u003ch2\u003eManaging Bodies, Spaces, and Social Dynamics\u003c/h2\u003e \u003cp\u003eIt is easy to imagine overdose response in a vacuum: One person is unconscious on the ground, a second hovering over them, nasal spray in hand\u0026mdash;a situation where knowledge and composure would seemingly suffice. In reality, reversals often unfold with complex choreography as responders manage the physical and social dynamics of the scene. Bodies are crumpled, doors are locked, bystanders are panicked or uncooperative. In these scenarios, revival becomes as much about managing a scene as saving a life.\u003c/p\u003e \u003cp\u003eOverdoses do not always unfold in a living room or on a park bench; space is often at a premium. Participants recounted reviving people who were in a bathroom stall, wedged between a toilet and tub, or slumped over in a cramped car. In these moments, participants had to decide between rescuing in place or spending precious seconds repositioning. Sometimes there was no choice at all \u0026ndash; the orientation of the scene prevented access to a nasal cavity for naloxone or a mouth for rescue breathing. These respondents faced the physical challenge of dragging someone out of a cramped car or maneuvering a limp body out of a small bathroom.\u003c/p\u003e \u003cp\u003eMost troubling were scenarios where persons who overdosed were behind closed doors and responders were forced to pick a lock or break the door down. Trish wasn\u0026rsquo;t using at the time of her most recent reversal, but her boyfriend was. She remembers him going into their upstairs bathroom, his normal space to use. Two minutes later, she heard a thump. Trish ran upstairs, knocked, and didn\u0026rsquo;t receive a response. Peering under the closed door, she could see her boyfriend\u0026rsquo;s crumpled body.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eSo I grabbed the hanger, shoved it in there, unlocked it, but then I couldn't shove him. Because he was in between the sink. His head was by the toilet and his butt and legs were by the door \u0026hellip; I sat on the floor and shoved with both feet. And I slid him at least a little bit. (Trish, Pennsylvania)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eBy the time Trish got the door open, her boyfriend was already cyanotic. She straightened his body, tilted his head back, and administered a dose of intranasal naloxone. He woke up enough to get down the stairs, but as soon they reached the bottom of the flight, he fell unconscious again. Trish gave a second dose, and after 10 agonizing minutes of rousing and waiting, her boyfriend finally awoke for good.\u003c/p\u003e \u003cp\u003eThe demands of overdose response extended beyond navigating spaces to handling the bodies themselves. Many participants shared stories about body shape and size presenting particular challenges. Shawn (California) sometimes turns over responsibility when the person who overdosed is a woman, typically smaller than himself, \u0026ldquo;because they\u0026rsquo;re already frail \u0026hellip; I don\u0026rsquo;t want to break nothing.\u0026rdquo; More commonly, participants had issues with larger individuals, who may be flipped on their stomach, stuck in an awkward position, or too heavy to move. Several participants discussed the difficulty of rescue breathing in these scenarios.\u003c/p\u003e \u003cp\u003eErin, who estimates she reverses more than ten overdoses a month, has only ever lost one person, a close friend. When he fell unconscious, she only had one nasal spray on hand, which she argued is not as effective as intramuscular naloxone. Two minutes later, with the nasal spray proving insufficient, Erin turned to CPR, which she was forced to perform alone when the only other person present left the scene.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI've got an almost 300 pound man on me. So imagine yourself doing this\u0026hellip;pum pum pum, phoo. Wait. Pum pum pum, phoo. After about two minutes of that, you're gonna almost exhaust yourself to where you pass out. I told the guy, I said please don't leave. I'm like, dude, I can do this. All you have to do is just stay here. That motherfucker [bystander] just left. \u0026hellip; I can almost save anybody. But I couldn't do it by myself. (Erin, California)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThe choreography of Erin\u0026rsquo;s response continued as she had to alternate between breathing and speaking with an unhelpful EMS dispatcher:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eWhen I called up the police they were like, why do you keep leaving the phone? \u0026hellip; I'm fucking saving somebody here. Get somebody out here. What the fuck are you asking me that for? I gotta go. Hold on. Pum pum pum, phoo. You know what I mean? It was really hard. I've never lost anybody in my whole life. Except that one person.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eErin was not unique in her experience of unsuccessfully seeking active support from others. Though some participants recounted collaborating well with others on reversals in the past \u0026ndash; one person rescue breathing while the other fetches the naloxone, for instance \u0026ndash; these experiences were the exception. Almost all described taking charge when others were present, trusting their own expertise and levelheadedness amidst panicked bystanders. Participants tended to feel confident in the lead, if not a little annoyed by a backdrop of crying, scrambling, and arguing. In many cases, responders encountered social dynamics that were not only distracting, but actively obstructive. Participants described needing to managing others\u0026rsquo; emotions, asking people to leave the room, and arguing with antagonistic bystanders over the best course of action.\u003c/p\u003e \u003cp\u003eMikey is accustomed to pandemonium during overdoses. He finds that others usually make the scene worse, not better. As he recalls when a friend overdosed on his rinse (the residue left over in the syringe or cooker):\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eEveryone's surrounding him, Cindy\u0026rsquo;s freaking out, trying to get him back \u0026hellip; She went to do CPR and she didn't plug his nose and I had to, like, throw her off. And she was fighting me off. She's like, no, get the fuck \u0026ndash; She knows that I can handle it. But, and it was fine. \u0026hellip; Almost every time, it's crowd control. Like, you hear one person yelling, everyone's yelling, everyone comes around, like I said, arguing over who can handle it better \u0026hellip; You just gotta not pay attention to them, just stay calm, and just get up in there and just give them mouth to mouth, you know, without permission. I don't need you to say it's okay, I'll kick you off if I need to, if you're not doing it right. (Mikey, Pennsylvania)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eMany participants encountered unhelpful bystanders, like one \u0026ldquo;petty\u0026rdquo; and \u0026ldquo;childish\u0026rdquo; woman who refused to hand over the naloxone to the participant because she wanted the experience of administering it herself. On the contrary, several participants found no help when they needed it. In most cases, these were bystanders who refused to call 911, typically for fear of legal repercussions. Arnold described a rare encounter where he was pushed by frustration to leave, a decision he regrets:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI was asked to administer meth to a guy [by his cousin] to bring them back, but I refused. Yeah, I refused. I said, the only way I'm willing to help is if you get your shit and everybody leaves and I stay with them and call 911. That's the help I'm willing to give. Now this time I felt really bad because he refused me. So I walked out of there leaving him the way he was, and I felt really bad about that. He didn't die. (Arnold, Michigan)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eThough Arnold\u0026rsquo;s decision to leave was rare among participants, it illustrates how social conflict can derail overdose response: Misaligned priorities, competing assessments of risk, or breakdowns in coordination among people present can disrupt response efforts and jeopardize survival. These accounts reveal how the imagined simplicity of naloxone administration dissolves into complex negotiations with physical spaces, uncooperative bodies, and chaotic social dynamics\u0026mdash;all while racing against time.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec13\" class=\"Section2\"\u003e \u003ch2\u003eDignity and Autonomy at the Edge of Death\u003c/h2\u003e \u003cp\u003eThe calculus of overdose response often extended beyond how best to save a life. In participant accounts, these events often presented ethical quandaries, where responders balance revival with respecting bodily autonomy and minimizing harm\u0026mdash;including the harms of lifesaving interventions themselves.\u003c/p\u003e \u003cp\u003eMany participants demonstrated sensitivity to the moral imperative of preserving human dignity, even in such tenuous circumstances. Some decried certain rousing tactics \u0026ndash; like heavy-handed slaps or ice in the pants \u0026ndash; as unnecessary and inhumane (\u0026ldquo;Don\u0026rsquo;t abuse them, man,\u0026rdquo; Erin, California). A few participants recounted briefly hesitating to reverse people in undress, recognizing the inherent intimacy of handling a nude body.\u003c/p\u003e \u003cp\u003eA person experiencing overdose is in a state of ultimate vulnerability, unable to advocate for their needs. A particularly fraught issue was what participants called the \u0026lsquo;do not resuscitate order\u0026rsquo; (DNR): Individuals who had demanded, should they fall out (i.e., appear to overdose), no attempt be made to save their lives. Participants shared that certain DNRers were despondent or lived with suicidal ideations, though others simply felt the risks were justified to avoid losing a good nod. Nearly all participants who encountered DNRers were obstinate about putting life first and facing the consequences (namely, the person waking up angry): \u0026ldquo;Nobody\u0026rsquo;s ODing on my watch \u0026hellip; You\u0026rsquo;re gonna have to want to die some other time,\u0026rdquo; (Chrissie, California). Most persons who overdosed were ultimately grateful, though even among those who awoke upset, participants remained undeterred in their resolve: \u0026ldquo;I\u0026rsquo;ve had a few friends, they were like, beating on my chest, saying why did I bring them back? Cause I always will. If I\u0026rsquo;m around, I\u0026rsquo;m gonna do that\u0026rdquo; (William, California).\u003c/p\u003e \u003cp\u003eFor Seth, however, DNRs are more complicated. Seth knows that life can be difficult in the throes of dependence, and wonders if a person with earnest intent deserves their wishes to be respected:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI mean, if I find that's what they really want, and they're in their house, their own home. Stuff like that. You know? I had a buddy, had cancer and had a bad heart and shit like that. He went out like that. \u0026hellip; I mean, a lot of them, a lot of us, that's how they feel. If they didn't get clean, you know, and turn around, they just feel like, oh, fuck it, you know, I've been struggling and my body hurts, you know? (Seth, Pennsylvania)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eUnlike medical DNRs, these informal declarations carried no legal weight, yet they could present profound moral dilemmas.\u003c/p\u003e \u003cp\u003eOf all the competing imperatives in overdose response, the specter of precipitated withdrawal most pervasively shaped participants' decisions. Most had experienced precipitated withdrawal themselves and carried visceral knowledge of the agonizing minutes and hours that can follow a revival: Disoriented wakefulness quickly gives way to sweating, chills, vomiting, diarrhea, and foreboding anxiety and craving. This embodied understanding created a specific tension: naloxone saves lives but can inflict immediate suffering on those saved.\u003c/p\u003e \u003cp\u003eParticipants navigated this tension differently. Some felt that a second chance at life justified temporary suffering and held no qualms about doing whatever it takes to complete a reversal. After all, many had themselves suffered such misery and came through on the other side. They explained how it is better to be safe than sorry: \u0026ldquo;Would you rather be sick or you\u0026rsquo;d rather be dead, bro?\u0026rdquo; (Mack, Pennsylvania). Others were extremely cautious about their approach, hesitating at each turn: How much should I use? Is a second dose necessary? How long should I wait? Should I even give naloxone at all?\u003c/p\u003e \u003cp\u003eLinda is thankful she has never had to administer naloxone to a loved one \u0026ndash; a situation that some participants described as carrying additional emotional weight \u0026ndash; though she came close during her husband\u0026rsquo;s suspected overdose. In retrospect, she believes he probably needed the lifesaving medication, but explains what made her hesitate:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eBeing afraid that I was wrong. That he didn't need it yet. \u0026hellip; Because it sucks so bad. Like, precipitated withdrawal is the worst. And I know if you get enough Narcan, that's what it'll basically do to you. So I'm, like, trying to judge. Am I correct on this decision? \u0026hellip; It definitely was what made me hesitate a bit. (Linda, Pennsylvania)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eLinda tries to wait at least five minutes before administering a second dose. \u0026ldquo;The least, the better,\u0026rdquo; she explained. Many others shared her sentiment \u0026ndash; even in moments of panic and imminent mortality, as instinct begs one to push the plunger, the pains of withdrawal must be measured. Chelsea recalls a few occasions where she woke up from an overdose and vomited extensively. These experiences informed her own approach to reversing. Now she tries rousing, rescue breathing, and chest compressions before reaching for naloxone.\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eI put that into perspective, how shitty I feel. I try to do everything before I try to bring them back, before I hit them with Narcan. I don\u0026rsquo;t just use it recklessly. You know? Some people are like, oh, they're nodding out. Hit them with the Narcan. \u0026hellip; And I'm like, gosh, that's so cruel. (Chelsea, Michigan)\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e \u003cp\u003eDeath is not the only hazard of overdose. Beneath the fog of sedation, control is abandoned and vulnerability laid bare. Each responder decides for themselves how the primacy of survival weighs against the dignity and autonomy of the voiceless.\u003c/p\u003e \u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this qualitative investigation, we find that overdose response is a practice that defies standardization. Protocol alone cannot resolve the social and physical demands, nor the cognitive and ethical tensions, intrinsic to saving a life within a complex and evolving landscape of drug supply and drug use patterns. Our findings reflect the experiences of 74 lay responders who have collectively performed hundreds of reversals, despite carrying the cumulative trauma of these interventions\u0026mdash;which many described as more distressing than their own overdoses. Their stories suggest that the practice of overdose response is defined by managed uncertainty \u0026ndash; reading an unfamiliar scene, navigating imperfect courses of action, resolving conflicting priorities. It is all the more astonishing that very few lost someone under their care.\u003c/p\u003e \u003cp\u003eOur findings build on emerging literature documenting the complexity of overdose response decision-making. Researchers have recently identified multiple decisional challenges in community naloxone administration in the United Kingdom and New York City, including dose, timing, and repeat administration [\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. These studies suggest that overdose response involves multiple decision points where several approaches may be appropriate, requiring contingent adjustments (depending, for instance, on whether the person awakens with withdrawal symptoms, hostility, mild physical and emotional reactions, or a combination of the above) [\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Our analysis extends these frameworks by revealing how lay responders navigate not just isolated decisions but cascading inflection and friction points that fundamentally shape each response trajectory.\u003c/p\u003e \u003cp\u003eThe complexity and urgency of revival suggests that community responders often operate through heuristics (mental short cuts) rather than systematic, deliberative reasoning [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e], a pattern well-documented among EMS providers and emergency physicians facing similar time pressures and incomplete information [\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e]. Our findings confirm that protocol gives way to improvisation when competing pressures do not conform to expectation. The implications are significant: if responders rely on pattern recognition and situational adaptation rather than standardized steps, training that emphasizes rote memorization may be fundamentally misaligned with actual practice. Furthermore, assumptions about \"proper\" overdose response often ignore pragmatic realities. For example, Wetteman et al. found that people remain reluctant to call 911 despite Good Samaritan laws, doubting legal protections will be honored in practice [\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e]. Our participants similarly described avoiding emergency services not from ignorance but from experientially grounded skepticism about law enforcement involvement.\u003c/p\u003e \u003cp\u003eProtocols are further complicated when they exhibit their own hidden ambiguities. For instance, Narcan package instructions state to wait 2\u0026ndash;3 minutes between doses of naloxone, while some participants recalled learning different ranges from overdose trainings or paramedics (e.g., 3\u0026ndash;5 minutes). Dosing interval ranges and variation across training protocols require responders to make real-time decisions about the appropriate interval for re-dosing, without clear guidance on the contextual factors on which to base these decisions. Our participants' experiences with time distortion compound this problem: If \u0026lsquo;three minutes is an eternity when you're watching somebody die,\u0026rsquo; an instruction to wait 2\u0026ndash;3 minutes becomes practically meaningless. Responders must ultimately rely on their own judgment about when 'enough' time has passed.\u003c/p\u003e \u003cp\u003eThe challenges our participants described \u0026ndash; ambiguous symptomology, bystander management, unfavorable physical spaces, patient dignity \u0026ndash; mirror those documented among paramedics in emergency scenarios [\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e]. Likewise, many adaptive practices, like pattern recognition, protocol deviation, peer learning, and reliance on intuition, are common in experienced paramedics [\u003cspan additionalcitationids=\"CR27 CR28\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e]. Yet community responders navigate these complexities without the training infrastructure, continuing education, institutional resources, and legal protections available to credentialed emergency workers. Addressing this gap requires rethinking how we prepare community members for overdose response.\u003c/p\u003e \u003cp\u003eOne goal of overdose education, particularly for populations likely to witness multiple overdoses, should be to instill adaptive expertise \u0026ndash; the ability to apply knowledge and skills to both familiar and unfamiliar cases [\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e]. Alternative pedagogical approaches to traditional skills-based training that acknowledge complexity rather than simplifying it, are needed. Foundational skills like naloxone administration and CPR remain essential; however, real-world response requires building on these basics. We propose three methods, each commonly used in medical training [\u003cspan additionalcitationids=\"CR32\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e], to consider in introductory and continuing education on overdose reversal. First, our findings indicate there are not always clear answers to questions of naloxone administration, supportive interventions, and aftercare. Training should encourage reflective interaction with scenarios where the 'right' response depends on context. Dialogic learning, based on the Socratic method, is an approach that emphasizes dialogue, questioning, and collective meaning-making rather than rote instruction [\u003cspan additionalcitationids=\"CR32 CR33\" citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e]. Learners engage with each other\u0026rsquo;s perspectives and experiences, co-constructing understanding and working through multiple answers to the same question. Dialogic learning may be complemented by a second pedagogical approach, problem-based learning, which presents structured but open-ended problems to solve [\u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e] \u0026ndash; for instance, a vignette where naloxone access is limited, bystanders are hostile, and/or the person who overdosed has expressed DNR wishes [\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e]. These approaches would ideally teach trainees to apply knowledge flexibly rather than only memorize fixed steps. Finally, the experiential knowledge of community responders cannot be underemphasized. Near-peer models, where trainings are co-facilitated by people who have reversed multiple overdoses, acknowledge the value of learned expertise that is not captured in protocols [\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e]. These approaches could enhance standardized curricula by preparing responders for the complex situations that go beyond standard protocols. We note that our participants described an array of strategies which invariably included a few that are likely ineffective and may delay critical interventions (e.g., ice baths). Any training, whether peer-facilitated or otherwise, would need to account for misconceptions as well as innovations.\u003c/p\u003e \u003cp\u003eParticipants described very few scenarios where naloxone was unavailable when needed, and these were typically overdoses that occurred away from their caches at home or in the car. Of greater concern was how to use the naloxone on hand effectively without precipitating withdrawal [\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e]. Many experienced responders described a preference for intramuscular naloxone, which allows dose titration\u0026mdash;starting with smaller amounts to minimize withdrawal while ensuring revival. Evidence is lacking on fractional intramuscular dosing, though naloxone is commonly titrated to effect intravenously in hospital [\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e]. Still, our recent analysis of 17 years of harm reduction program data suggests withdrawal symptoms are significantly less common when naloxone is administered intramuscularly [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e]. Despite these potential advantages, intranasal naloxone remains the dominant formulation in distribution programs due to its ease of use and broad acceptability [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e]. Additionally, social stigma surrounding needles\u0026mdash;including concerns about needle debris and negative associations with injection drug use and communicable disease transmission\u0026mdash;may limit community acceptance and uptake of intramuscular formulations [\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e]. Taken together, these findings suggest that different naloxone products used for community administration offer distinct advantages, and that participants varied in their preferred routes of administration based on experience and context. Ensuring access to multiple community-use naloxone products may better accommodate responder needs and preferences, particularly among experienced responders. Importantly, the perspectives of people who use drugs on their preferred formulation for their own potential overdoses should also be considered, though research on these preferences remains limited. The added benefit of intramuscular naloxone's lower cost [\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e] makes expanded access not only clinically sound but economically advantageous, allowing programs to stretch limited budgets while honoring responder expertise and choice.\u003c/p\u003e \u003cp\u003eThe burden placed on community responders raises important ethical questions. Buchman et al. argue that expecting these populations to serve as de facto emergency responders shifts responsibility for a public health crisis onto those least resourced to manage it [\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e]. Yet Rochester \u0026amp; Graboyes found that many people who use drugs experience overdose reversal as empowering, providing purpose and community connection [\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e]. Our findings support both perspectives: participants demonstrated remarkable expertise while navigating extraordinary challenges with minimal support. Several participants had reversed dozens of overdoses, with some estimating over 100 reversals\u0026mdash;experience comparable to many emergency medical professionals. Yet their life-saving work remains largely invisible, uncelebrated, and unsupported by public health infrastructure. The solution is not to shift responsibility away from community responders\u0026mdash;who will remain the first line of defense regardless of policy\u0026mdash;but to recognize and resource their essential role. This includes training that reflects real-world complexity, emotional support for the trauma of repeated life-or-death interventions, and public acknowledgment and celebration of their public health contributions, which are often given thanklessly and at significant personal cost.\u003c/p\u003e \u003cp\u003eOur study has some limitations. Although overdose is undoubtedly a memorable event, accounts were retrospective and narratives may be simplified. Likewise, participants may have exhibited social desirability bias and avoided discussing unsuccessful reversals or encounters that might evoke embarrassment, shame, or perceived failure.\u003c/p\u003e \u003cp\u003eIn addition, participation was voluntary, and individuals willing to speak at length about overdose reversal may differ systematically from more hesitant or reluctant participants. Those who are uncertain, fearful, or conflicted about their actions\u0026mdash;particularly individuals who did not intervene or who disengaged from an overdose scene\u0026mdash;may be less inclined to share their experiences, and their perspectives are likely underrepresented in this analysis.\u003c/p\u003e \u003cp\u003eOur study is limited to three metropolitan areas in Michigan, Pennsylvania, and California; overdose reversals may differ in other places based on local drug market composition, harm reduction access, and drug policies. Our primary recruitment sites were harm reduction programs, which likely misses perspectives from bystanders who reverse overdoses outside harm reduction networks.\u003c/p\u003e \u003cp\u003eMany participants also reported high numbers of reversals, and as such, our findings may not reflect the experiences of those with less exposure. As with any qualitative study, the aim of this research is not generalizability but rather to capture the rich perspectives of a seldom heard group that are often missing or masked in quantitative research. Nonetheless, we note that multiple reversals was not an eligibility criterion, and the depth of experience captured in our analysis may be common, at least among people who attend harm reduction programs. One previous study defined \u0026lsquo;supersavers\u0026rsquo; as those with three or more naloxone administration events [\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e]. Our findings suggest this is likely a conservative definition that misses the routinization of overdose over time [\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e]. Indeed, at this stage in its evolution, the overdose epidemic is better understood as endemic.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eOur study demonstrates that overdose response defies protocol, requiring navigation of complex physical, social, and ethical challenges. The 74 participants\u0026mdash;many with extensive experience responding to overdoses\u0026mdash;revealed expertise developed through repeated life-and-death decisions: reading ambiguous symptoms, managing chaotic environments, and balancing survival against suffering. This embodied knowledge deserves recognition as legitimate expertise. Public health approaches must evolve beyond 'naloxone saves lives' to acknowledge the full complexity of community response, providing training that develops judgment, ensuring access to preferred formulations, and supporting those who serve as our invisible frontline against overdose mortality.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cem\u003eEthics approval and consent to participate:\u0026nbsp;\u003c/em\u003eThe study was approved by the University of North Carolina-Chapel Hill Institutional Review Board (#24-0265). A waiver of written informed consent for interviews was approved by the UNC IRB for participants to minimize risks associated with creating signed records of sensitive information. Verbal consent was obtained and documented by interviewers, with no signatures or identifying information collected.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eConsent for publication:\u0026nbsp;\u003c/em\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAvailability of data and materials:\u0026nbsp;\u003c/em\u003eData may be made available upon reasonable request to the corresponding author.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCompeting interests\u003c/em\u003e: The authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eFunding\u003c/em\u003e: The study was supported by the U.S. Food \u0026amp; Drug Administration Center for Drug Evaluation \u0026amp; Research under a broad agency announcement (75F40122C00193, PI Dasgupta). As part of this partnership, FDA scientists identified priority research questions pertinent to the regulation of overdose reversal products, provided input on the interview guide, and participated in monthly data review meetings. The UNC research team maintained independence in data collection, analysis, and interpretation, with FDA colleagues contributing as subject matter experts and sharing perspectives relating to regulatory and public health considerations.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAuthors\u0026rsquo; contributions:\u0026nbsp;\u003c/em\u003eALS was responsible for conceptualization, methodology, investigation, formal analysis, writing \u0026ndash; original draft preparation, project administration. DCC was responsible for formal analysis, writing \u0026ndash; review \u0026amp; editing. EJG was responsible for conceptualization, methodology, formal analysis, writing \u0026ndash; review \u0026amp; editing. JM, ZDWD, AB, MV, SA, SJ, MDS, EJW and MESM were responsible for conceptualization, resources, writing \u0026ndash; review \u0026amp; editing. ND were responsible for conceptualization, funding acquisition, writing \u0026ndash; reviewing \u0026amp; editing.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAcknowledgements:\u0026nbsp;\u003c/em\u003eThe authors wish to acknowledge all participants for candidly sharing stories that carry trauma and loss.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclaimer\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe contents of this article are solely the responsibility of the authors and do not necessarily represent the official views of the US Food and Drug Administration.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eNational Institute on Drug Abuse. Drug Overdose Deaths: Facts and Figures [Internet]. 2025 [cited 2024 Sept 6]. 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Who is using take-home naloxone? An examination of supersavers. Harm Reduct J 2022 June 18;19(1):65.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePro G, Richoux C, Bolt M, Kincade A, White R, Kasper C, et al. Factors Associated With Self-Reported Overdose Reversals Using Naloxone in Little Rock, Arkansas: Implications for Harm Reduction Service Delivery in the US South. J Drug Issues. 2025;55(4):533\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Footnotes","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003e Naloxone is labeled for intramuscular injection. Intralingual injection has not been studied and may introduce concerns such as bleeding and airway compromise.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"harm-reduction-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"harj","sideBox":"Learn more about [Harm Reduction Journal](http://harmreductionjournal.biomedcentral.com/)","snPcode":"12954","submissionUrl":"https://submission.nature.com/new-submission/12954/3","title":"Harm Reduction Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"People who use drugs, overdose, harm reduction, naloxone, peer care, overdose reversal, qualitative research","lastPublishedDoi":"10.21203/rs.3.rs-9140958/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9140958/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eThe practices of lay responders remain poorly understood despite overdoses increasingly occurring outside medical settings. This qualitative study examined how 74 people who use drugs in Pennsylvania, Michigan, and California reverse overdoses in real-world conditions. Semi-structured interviews explored participants' overdose response experiences across hundreds of reversals. Reflexive thematic analysis informed by Critical Decision Method identified two types of critical moments that shape response trajectories: inflection points requiring decisions, and friction points creating obstacles. We organized the findings into four themes: (1) the interplay between preparation and adaptation, with responders departing from standardized approaches based on contextual factors like suspected drug type and characteristics of the person overdosing; (2) perceptual and material precarity (e.g., time distortion, incomplete information, and device failures); (3) managing bodies, spaces, and social dynamics (e.g., breaking down locked doors and controlling panicked bystanders); and (4) ethical tensions around dignity, autonomy, and precipitated withdrawal, with most participants having experienced withdrawal themselves. Participants navigated these complexities through pattern recognition, improvisation, and experientially developed heuristics. Despite facing multiple simultaneous overdoses, hostile environments, and material constraints, few participants reported unsuccessful reversals. Participant accounts reveal that overdose response defies simple procedural steps, requiring embodied knowledge developed through experience. Findings suggest value in trainings that build adaptive expertise, having multiple naloxone formulations available including intramuscular options, and providing support systems for community responders.\u003c/p\u003e","manuscriptTitle":"More than Medicine: The Complex Choreography of Community Overdose Response","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-05-06 02:06:51","doi":"10.21203/rs.3.rs-9140958/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"editorInvitedReview","content":"","date":"2026-05-16T21:16:22+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-02T02:58:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"215818758317806437716221116445318607633","date":"2026-04-29T16:07:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"293480169100139971426122517752835050976","date":"2026-04-27T21:28:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"280419491817207180220979816567112368374","date":"2026-04-27T16:39:43+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"52670411488763559121602195361444169566","date":"2026-04-27T09:41:43+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-27T03:52:43+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-03-17T14:25:39+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-17T14:25:05+00:00","index":"","fulltext":""},{"type":"submitted","content":"Harm Reduction Journal","date":"2026-03-16T18:05:01+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"harm-reduction-journal","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"harj","sideBox":"Learn more about [Harm Reduction Journal](http://harmreductionjournal.biomedcentral.com/)","snPcode":"12954","submissionUrl":"https://submission.nature.com/new-submission/12954/3","title":"Harm Reduction Journal","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"46856ba1-d5c5-4c34-8a6b-3c1738c25b2d","owner":[],"postedDate":"May 6th, 2026","published":true,"recentEditorialEvents":[{"type":"editorInvitedReview","content":"","date":"2026-05-16T21:16:22+00:00","index":35,"fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-02T02:58:19+00:00","index":33,"fulltext":""},{"type":"reviewerAgreed","content":"215818758317806437716221116445318607633","date":"2026-04-29T16:07:51+00:00","index":31,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-06T02:06:51+00:00","versionOfRecord":[],"versionCreatedAt":"2026-05-06 02:06:51","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9140958","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9140958","identity":"rs-9140958","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}