We present, to our knowledge, the first published data of drug overdose among people who use drugs accessing harm reduction services in selected cities in South Africa. The findings from this small pilot study highlight the likely burden of overdose. The study points to probable significant (and largely undocumented) overdose-related morbidity and mortality among marginalised people who use drugs in South Africa. This initial study highlights the critical need to better quantify and understand overdoses to inform policy and programming. The characteristics of this sample are similar to people who access harm reduction services at organisations that are part of the South Africa Community Epidemiology Network on Drug Use .
This study found that opioid overdoses are occurring within the population of people who use drugs in the selected cities. Over a third of the participants experienced an overdose in the last year. Over two-thirds were aware of overdoses occurring among their peers, presenting an important opportunity to train peers in harm reduction principles, including recognising and responding to an opioid overdose. Our pilot study has also demonstrated the willingness of people who use drugs who access harm reduction services to report personal experiences of drug overdose. The ability of this approach to obtain information on overdose experiences among peers suggests that the community of people who use drugs share their experiences among themselves. The sense of community is important because peers are often the first ones that can phone for medical assistance in the case of an overdose. In many settings globally, peers play a critical role in saving lives by reversing potentially lethal overdoses .
Several known risk factors associated with fatal drug overdose were reported. These risk factors include homelessness, daily injection of heroin and polysubstance use . This information indicates a significant opportunity to direct increased efforts to reduce the risk of morbidity and mortality among this group of individuals. Further risk reduction can also be achieved through increased access to opioid substitution maintenance therapy . Further, an overdose can be mitigated through community awareness and training, and the wide distribution of naloxone .
While the sample is small and comprised mostly of homeless people, there was heterogeneity in the responses. Caution should be exercised in generalising from these participants. However, despite the small sample, the majority (64%) had never heard of naloxone, yet most respondents were willing to carry it on their person in case of an overdose, should it become available and accessible. Given that most participants who had overdosed in the past year reported that they were not alone at the time of the overdose, participants' willingness to carry naloxone presents an opportunity to equip the people closest to those at risk of overdose with a tool proven to prevent death. The findings align with the WHO’s guidelines for community management of opioid overdose . The WHO guidelines recommend that people who are likely to witness an opioid overdose, very often friends and family members of people who use opioids, should be given access to naloxone and training on how to recognise and respond to an overdose . As a result, at least 15 countries globally have implemented programmes which include access to naloxone and overdose training, demonstrating an increase in knowledge and competencies around responding to an opioid overdose [18, 19]. The rapid scale-up of overdose prevention programmes (including take home naloxone) is possible in low- and middle-income settings, provided there is political will . Programmes that improve peer and family responses to overdose situations decrease rates of overdose deaths when compared to programmes that do not include family and peers . Brief education and training of opioid users in recognising and responding to an overdose of a peer improved overdose response .
The existing legislation in South Africa does not include Good Samaritan laws . The provision of naloxone is limited to self-use only, requiring a prescription by a medical doctor. The risk of prosecution makes it challenging to ensure peers, who are often opioid users themselves are equipped to respond to a potentially lethal overdose. Neither the draft national standards for emergency medical services (2021)  nor the Health Professions Council of South Africa’s clinical practice guidelines for emergency service providers (2018)  include a requirement for emergency medical service providers to report drug overdoses to the police.
Finally, the study found that most people were comfortable calling for help in the event of an overdose. However, a notable proportion (26%) were either uncomfortable calling for help or did not know whom to call. Globally, there is a reluctance, particularly among people who use drugs, to calling for help . One of the most significant predictors of calling for help is the drug policy environment and the related charges one might face if arrested at the site of an overdose . There is very little data on the facilitators and barriers to calling for help to respond to an overdose in South Africa. A report by the South African Network of People Who Use Drugs revealed that people who use drugs experienced discrimination and delayed response times when calling ambulances to respond to medical emergencies . In the USA, people most often cite the fear of police involvement as the reason for low rates of calling for help in the case of a drug overdose [26, 29]. Good Samaritan Laws provide limited indemnity from prosecution if someone responds to an overdose and calls 911 to seek medical help. In the USA, Washington was the second state to implement Good Samaritan laws. In a survey of 355 opiate users in Washington, when informed of the laws, 88% reported they would phone for medical assistance in the case of an opioid overdose .
In South Africa, the hostile engagement between people who use drugs and law enforcement continues, as noted by harassment and often confiscation and destruction of injecting equipment (SAMRC, 2020). Encouragingly, efforts are ongoing to enable collaboration between health and security actors towards public health and safety .
Over the past decade, as global harm reduction efforts have focused on making naloxone more accessible and available in overdose situations, first responders have been equipped with naloxone . In many settings globally, law enforcement officers are frequently first to arrive on the scene of an emergency. When officers carry and are prepared to use, they can administer naloxone before other responders arrive, increasing the likelihood of effective overdose reversal .
In the case of an opioid overdose, death does not usually occur immediately, often allowing time for a life-saving intervention. Overall, 76% of individuals surveyed in this study were aware of opioid overdoses occurring among their peers; however, very few people who experienced an opioid overdose received medical attention; hence, it is critical to ensure that those who are most likely to be at the scene of a drug overdose have the capacity to recognise and respond to an opioid overdose. Self-report data from PWID are critical to understanding personal and witnessed overdose events. Many cities around the world have begun training bystanders and peers on overdose prevention and response, including self-reporting.
Peers and bystanders represent a critical part of any comprehensive overdose response plan. For example, the WHO and the United Nations Office on Drugs and Crime’s Stop Overdose Safely project in Kazakhstan, Kyrgyzstan, Tajikistan and Ukraine demonstrated the effectiveness of community naloxone distribution . The project involved the training of 14,263 potential opioid overdose witnesses over eight months. Trainees were provided with take home naloxone. Thirty-five per cent (478/1388) of participants engaged in the project evaluation cohort witnessed an overdose within six months following the training, among whom 89% used naloxone with 98% of the victims surviving . There is an important need to maximise the potential role of bystanders and communities of people who use opioids in South Africa and other African contexts to respond to opioid overdoses.
Our South African pilot study has several limitations. First, the small sample and convenience sampling of participants who access harm reduction services limit the generalisability of findings. The available resources, accessibility of participants, and feasibility of integrating the survey into service delivery influenced the sample size. However, the pilot study has established preliminary data that points towards a high prevalence of overdose among people who use drugs. The value of assessing the feasibility and acceptability of integrating overdose assessment into harm reduction service in a more robust manner has been demonstrated. The small size of this study limits the degree to which it can be used to directly inform policy.
Second, the survey tool was not validated, and the amount of missing data limited the analysis that was possible. Missing data fields were caused primarily by the use of paper-based tools with free text and the option of participants to decline answering questions. Notably, many participants declined to provide demographic information or information about their experiences with overdose.
Third, the study did not explicitly ask participants about access to or use of health-related or harm reduction services. However, given that recruitment was performed by harm reduction service providers, it is possible that the study cohort likely has increased exposure to information about responding to an overdose. As a result, it is likely that they would have felt more comfortable calling for help or administering aid when responding to an overdose. It cannot be assumed that the same level of knowledge and willingness to phone for medical assistance would be reported among groups with less exposure to harm reduction organisations.