Editorial: Responding in crisis: Experiences of compassion, stigma, and professionalism among emergency personnel during the opioid epidemic

More than 2 decades into the ongoing opioid epidemic, an estimated 2.1 million people are affected by opioid use disorder with a record-high number of deaths exceeding 93,000 in 2020 in the United States alone.1, 2 First responders, including police, firefighters, and emergency medical services clinicians are often the first to provide assistance in opioid-related emergencies. However, the system in which first responders operate is poorly equipped to manage these encounters. Structurally, the protocol-based approach of first-responder care is not designed to manage the chronic and complex nature of addiction. As emergency care practices are rarely coupled with a clear path to effective long-term treatment options, emergency personnel provide frequent (and often repeated) care to these persons, repeatedly bearing witness to the devastating social and physical effects of opioid addiction. As a result, many emergency personnel feel frustrated and helpless when it comes to encounters involving opioid use disorder. In these trying circumstances, it is critical to understand emergency professionals’ attitudes and beliefs toward people who use opioids. In this issue, Metcalf et al’s “Compassion, Stigma, and Professionalism among Emergency Personnel Responding to the Opioid Crisis: An Exploratory Study in New Hampshire, USA” presents findings from a series of qualitative interviews with front-line emergency personnel regarding attitudes and beliefs toward people who use opioids. This study provides an important look at the experiences of emergency personnel in caring for those affected by opioid use disorder and offers a framework for exploring how these experiences may shape their beliefs and attitudes. This investigation is critically needed as emergency personnel often provide the first—and often the only—care for those struggling with opioid use disorder. From this exploratory work emerge 3 core themes: when caring for opioid abuse victims, emergency personnel struggle with (1) compassion, (2) stigma, and (3) professionalism. Compassionate beliefs included those that reflected a desire to alleviate suffering following the witnessing of another's distress. Stigmatizing beliefs, defined as negative biases toward those who use opioids, also included the more nuanced categories of suspicious and cynical attitudes. Interestingly, these categories were not mutually exclusive among participants. Instead, most emergency personnel expressed conflicted perspectives with varying degrees of both compassion and stigma. Many emergency personnel also voiced a “sense of duty” and “professionalism” that take precedence over any personally held biases toward people who use opioids. Nevertheless, attitudes of “cold professionalism” by emergency personnel in the absence of compassion may be perceived by people who use opioids in much the same way as stigma.3 Perceived stigma from emergency personnel may negatively influence opioid users, making them less willing to seek care.4, 5 Holding stigmatizing beliefs may also influence emergency personnel's own help-seeking for mental health needs.6 It follows that the degree to which emergency personnel respond with empathy and understanding to those they encounter in their work may influence the degree to which they allow themselves and their colleagues latitude and grace in managing the challenges of the work. Thus, Metcalf et al’s work suggests a need to identify ways of wiping out stigmatizing beliefs among emergency personnel. Interestingly, the authors found that personal experience with individuals affected by opioid use disorder was associated with greater compassion, regardless of general opinions disclosed about people who use opioids. Given that personally witnessing recovery shifted participants’ attitudes about opioid addiction, there may be value in exploring the use of the celebration of cardiac arrest model (wherein emergency personnel are connected with members of the community who have survived cardiac arrest).7 Connecting with community members who have moved into recovery from addiction may allow emergency personnel to see the positive consequences of their efforts, rather than only the repeated exposure to those who continue to struggle with addiction. Although possessing the common limitations of exploratory work, Metcalf et al’s study is an important first step, prompting us to explore the impact of stigma and compassion upon emergency personnel care for opioid use disorder. Future research should continue to disentangle how stigma and compassion influence emergency personnel interactions, not only with those experiencing opioid use disorder but also those living with other forms of addiction and mental health concerns. Identifying and addressing the root causes of stigma held by emergency personnel are paramount. We cannot depend on professionalism alone to ensure effective communication and appropriate care for persons affected by opioid use disorder or any other stigmatized conditions. The authors have no conflicts of interest to report.

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