First Responder Mental Health

Exposure to trauma is a common occurrence during the lifetime of individuals. It has been documented that approximately 60% of men and 50% of women experience at least one traumatic event during their lifetime (United States Department of Veteran Affairs, 2019). This finding is even more prevalent for first responders (FRs) given their profession. For example, police officers experience, on average, over three traumatic events, also known as critical incidents, during a 6-month period (Patterson, 2001). When responding to critical incidents, they are not only exposed to injury and death but are also susceptible to potentially disturbing emotional and cognitive experiences. Because of this, a growing amount of research has investigated the adverse consequences of being a FR (Carey et al., 2011; Jones et al., 2018).

Notably, FRs are at an increased risk of developing psychological and physiological trauma due to repeatedly responding to high-stress situations (Mccaslin et al., 2006; Patterson et al., 2016). FRs exhibit increased rates and symptoms of posttraumatic stress disorder (PTSD; Austin-Ketch et al., 2012; Wagner et al., 2010; Wagner & O’Neil, 2012), major depressive disorder, generalized anxiety disorder, sleep disturbances (Jones et al., 2018), and substance use (e.g., problematic drinking; binge drinking behavior, current nicotine use, overuse of caffeine; Carey et al., 2011; Haddock et al., 2017) compared to the general population. Disproportionately high rates for suicidal ideation and suicide attempts in the FR population are also of concern (Jones et al., 2018; Stanley et al., 2015; Violanti et al., 2013). More specifically, police officers, firefighters, and paramedics are more likely to die by suicide than in the line of duty (Carleton et al., 2018; Heyman et al., 2018). For example, in 2019, 235 officers died by suicide (Blue H.E.L.P., n.d.), compared to 161 deaths in the line of duty (Officer Down Memorial Page, 2019). Similarly, 120 firefighters died by suicide in 2019 (Firefighter Behavioral Health Alliance, 2021), compared to 62 who died in the line of duty (U.S. Fire Administration, 2020).

Prevalence of the Opioid Epidemic

Compounding their already stressful job duties and the psychological consequences of the profession, FRs are now faced with the opioid epidemic and are being profoundly affected by it (Chiu et al., 2018; Drug Enforcement Administration, 2017; Pike et al., 2019). In 2017, the United States Department of Health and Human Services (HHS, 2019) declared a public health emergency due to the rapid rise in synthetic opioid overdoses. Data collected by the Tennessee Department of Health (TDH, 2020) confirmed that of 1818 Tennessee overdose deaths in 2018, approximately 70% were from opioids. Tennessee’s opioid overdose death rate is 19.9 deaths per 100,000, higher than the national average of 14.6 deaths per 100,000 (National Institute on Drug Abuse, 2020; TDH, 2020). In 2018, more Tennesseans died from fentanyl than they did from prescription opioids (TDH, 2020), introducing new personal safety concerns for FRs, such as exposure to fentanyl (Howard & Hornsby-Myers, 2018).

Shift in Profession due to Opioid Epidemic

With the escalating rates of opioid overdoses in Tennessee and across the United States, many FRs have had to shift their work roles to meet the demands of the epidemic and the influx of medical calls. Originally, paramedics were the only FRs allowed to administer the drug naloxone. However, in recent years, naloxone administration trainings have spread throughout law enforcement and firefighter departments, and although there has been positive feedback for these trainings (Davis et al., 2014), the heightened number of medical calls related to opioid overdoses is increasing the likelihood of FRs being exposed to opioid-related traumatic events.

In addition to calls where an individual tragically dies from overdose, FRs may also be responding to repeated overdoses in the same individuals (Hasegawa et al., 2014; Larochelle et al., 2016; Olfson et al., 2018), as well as at risk of contact overdoses (Chiu et al., 2018), needle stick injuries (Cepeda et al., 2017), and bloodborne pathogens (e.g., human immunodeficiency virus and hepatitis C; Cepeda et al., 2017; United States Department of Labor, n.d.), adding to the stress of their job. With the increasing frequency and intensity of overdose-related traumatic experiences, the cumulative impact on the overall mental health of the FRs should be of urgent concern for emergency personnel agencies.

The Present Study

Given the psychological strain placed on FRs discussed above, a need for evaluating the effects of the opioid epidemic on this population becomes evident. While several critical studies have investigated the significant impacts of trauma on the psychological well-being within the FR community, surprisingly, little attention has been paid to the outcomes experienced by FRs attending to overdoses. Pike and colleagues, (2019) conducted a mix-methods study assessing the impact of the opioid epidemic on FRs, and through 11 qualitative interviews, they identified that FRs are frustrated with the increased workload, as well as exhibiting feelings of helplessness, worry, and sadness. The present study aimed to expand on Pike and colleagues, (2019) findings and to continue addressing the lack of research on the effects of the opioid epidemic in the FR population.

Informed by research investigating other stressors on FRs and to ensure a bottom-up understanding of the profiles of stressors, the present study used semi-structured qualitative interviews to explore how the increase in opioids, opioid-related harm, and opioid-related death within Tennessee rural-serving counties has affected FRs. More specifically, the present study aimed to investigate FR perspectives on how the opioid epidemic has affected their well-being, as well as the resources available to them following opioid-related calls.

Method

Participants

Participants (N = 30) were FRs age 21–63 (M = 41.23, SD = 12.48) recruited from Tennessee rural-serving counties (see Table 1). All participants met the following inclusion criteria: (1) at least 18 years old; (2) a law enforcement officer, firefighter, or paramedic; and (3) had directly participated in at least one opioid-related critical incident in Tennessee (e.g., utilizing Naloxone, implementing basic or advanced life support on a patient using substances, engaging in arrests related to illegal opioid use/distribution). The sample was unitary in that all participants self-identified as White/European American, and 93% of the sample identified as male. Forty-three percent of the sample identified as law enforcement officers (n = 13; e.g., police, sheriffs), 30% as firefighters (n = 9), 13% as both firefighters and paramedics (n = 4), 10% as paramedics (n = 3), and 3% as both firefighter and a law enforcement officer (n = 1).

Table 1 Descriptive statistics of demographics
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Procedures

After the institutional review board approved the present study’s procedures, participants were recruited through email, phone calls, and word of mouth. Prospective participants’ contact information was acquired via the agency’s website, as well as by sending recruitment emails to chiefs/captains explaining the purpose of the study and asking them to forward the information to their employees. In these emails, flyers were attached with additional information pertaining to the study. From there, the prospective participant would contact the principal investigator directly or the chief/captain would email back with a prospective participant’s contact information. Participants did not receive an honorarium for participating in the study. Previous research has presented a range of recommended sample sizes for qualitative research, as well as argued that qualitative researchers should continue recruiting until the point of saturation (Hennink et al., 2017). Given this, the present study recruited participants until new data did not develop new findings, and instead, themes began to repeat.

Upon completing the consent process that outlined limits of confidentiality, participant rights, and the potential effects of participating, one-on-one semi-structured interviews (N = 30) were conducted, each lasting approximately 30 min to one h. One interviewer (i.e., the first author) conducted all interviews and had no previous relation with the participants. Furthermore, due to the onset of the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreak and based on requirements by the IRB, face-to-face interviews (n = 6) transitioned to telephone interviews (n = 24) to maintain participant and interviewer safety.

Open-ended questions were derived from the semi-structured interview guide that was developed in consultation with psychologists, counselors, and FRs, and piloted with FR personnel from outside the participant sample. Questions were constructed following a phenomenological approach including six core questions and within those, were additional probing questions (Creswell, 2013). An example of a main topic question was “can you please describe your typical thoughts and feelings when attending to opioid-related incidents” followed by a probing questions of “how do you think these circumstances have translated into other areas of your life?” A digital audio tape recorder was used to record all participant responses. Upon completing the interview, a demographic questionnaire was provided and completed by each participant.

Data Analyses

This study was exploratory in nature, implying that the primary investigator was looking at a phenomenon that has yet to be explored, and had no preconceived assumptions about the data. A phenomenological approach was utilized throughout the research study to explore individuals’ lived experiences as they relate to the shared phenomenon of repeated exposure to the opioid epidemic. Phenomenology was fitting for this study as the researchers sought to develop a deeper understanding of the participants’ experiences rather than develop a theory (Creswell, 2013). To get to the essence of this phenomenon, researchers used horizontalization (i.e., the highlighting of significant statements during the coding process) after transcribing the interviews, thus resulting in the creation of themes and descriptions of what the participants are experiencing as well as the context of these experiences (Creswell, 2013).

After all data was collected, audio recordings were de-identified and transcribed verbatim. To increase provisions of trustworthiness, independent parallel coding was utilized involving an initial coder and a second coder (Thomas, 2006; Behar-Horenstein, slide 20). The first coder, the primary investigator (T. N.), analyzed and developed a set of categories (i.e., codes) that established the initial results, while the second coder, a trained research assistant (E. B.), was given the research objectives and raw data to create a second set of categories (Behar-Horenstein, slide 20). In addition, a third coder (M. G.) was consulted to assist with (1) mitigating different perspectives (n = 2 codes); (2) ensuring consistency of categorization, thus minimizing coding error; and (3) checking the finalized categories that were developed against the data to decrease subjectivity. Overall, inter-rater reliability was assessed using Cohen’s kappa coefficient (83%, k = 0.57; Landis & Koch, 1977), with all discrepancies ultimately resolved.

The data were analyzed using the software NVivo 12 (QSR International, 2020), which helped categorize themes throughout the raw data and assign them to different codes. In vivo coding (i.e., actual spoken words or phrases from the participant; Manning, 2017) was utilized to create the various codes. Codes that had the same meaning were ultimately combined, and codes lacking in references were removed.

Theme creation followed the steps of the following: (1) a quote from a participant such as “…any little incident that pops up, you blow up.” (Participant 5, firefighter/paramedic) was identified, (2) the statement was highlighted as a significant experience through the process of horizontalization, (3) a cluster of similar meanings across different participants were combined together, and (4) the cluster was shaped into a collective theme related to the symptom of hyperarousal (Creswell, 2013). The “Results” section supports the themes and examples from the data, ultimately creating a deeper understanding of what and how these individuals are experiencing the phenomenon. Please contact the corresponding author to request the data.

In the presentation of the results, due to the small sample size of paramedics and paramedic/firefighters and to further uphold confidentiality of participants, these samples were grouped together and will be identified as paramedics in the supporting quotes. Similarly, given that there was only one law enforcement officer/firefighter, this participant will be identified as a law enforcement officer in the quotes. Of note, the semi-structured interview was not constructed to determine whether FRs met formal diagnostic criteria for any particular mental health disorder. However, participants often self-identified concerns that aligned with symptoms of posttraumatic stress (PTS) and secondary traumatic stress (STS) symptoms.

Results

The responses to the semi-structured interview questions revealed three themes that were present across participants including (1) opioid epidemic burden on mental health, (2) variable availability and effectiveness of resources, and (3) identified roles of FRs in reducing the impact of the epidemic. Please refer to Table 2 for the subthemes and Table 3 for additional supporting quotes.

Table 2 Recurring themes and subthemes
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Table 3 Additional quotes to support the themes and subthemes
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Theme 1: Opioid Epidemic Burden on First Responder Mental Health

As a result of FRs repeatedly being faced with ambiguous and threatening situations when attending to opioid-related calls, they are experiencing mental health repercussions, supporting the first theme of opioid epidemic burden on FR mental health. This theme addressed the first aim of the study that sought to explore how the increase in opioids, opioid-related harm, and opioid-related death within Tennessee rural-serving counties has resulted in psychological repercussions in FRs. More specifically, the opioid epidemic burden on FR mental health theme is related to both the participant’s and their colleague’s mental health regarding working in one of the highest opioid-using states, as represented by the appearance of subthemes of PTS and STS symptoms.

Subtheme 1.1: Posttraumatic Stress Symptoms

The first subtheme that appeared across interviews was PTS symptoms. These symptoms included intrusion (i.e., the traumatic event(s) are re-experienced through distressing memories, nightmare, flashbacks, psychological distress, or physical reactivity); avoidance of trauma-related stimuli, negative cognition, and mood (i.e., negative thoughts or feelings that began or worsened after the traumatic event(s), such as negative affect, self-blame, or exaggerated negative beliefs about oneself or the world); and hyperarousal (i.e., trauma-related reactivity that began or worsened after the traumatic event(s), such as irritability, risk-taking behavior, or hypervigilance; Diagnostic and Statistical Manual or Mental Disorders, 5th Edition [DSM-5], 2013). Several participants also disclosed how these symptoms have consequently resulted in occupational and familial impairment.

Intrusion: You find a 30-year-old mother dead from a drug overdose with a needle in her arm and you’ve got a three-year-old child laying here on the floor crying, that’s what I don’t think you could train somebody for. They’re gonna relive that every time they see a drug overdose. You’re gonna see that three-year old kid that doesn’t have a mother anymore. (Participant 5; Paramedic)

Avoidance: ...to this day I don’t talk about it much. It kinda makes me wanna cry. You know, a lot of these guys are walking around with these lifesaving medals; the little green medal that says you saved somebody’s life, or they feel like your actions could have saved somebody’s life. I wish I had one of those today, not because I wanna wear some stupid medal, but I wish that little fella would have lived. He wasn’t even two years old, and all because somebody got stupefied on medication, rolled over on him, and smothered him to death. (Participant 25; LEO)

Negative Cognition and Mood: It’s like a domino effect; if they die that not only affects their family but it affects us emotionally because at times we feel like ‘Is there anything else I could’ve done?’ (Participant 28; firefighter)

Hyperarousal: I don’t sleep good anymore because when you get that bad call it tends to linger in your mind, you know. You care when you find someone dead. You can’t erase that. You can’t go back, and it weighs on your mind how this happens, and why he went through it, how bad his family members hurt, and so sleep deprivation gets you on the physical and mental side. And it does affect relationships big time because I’ve worked a couple of deaths in one week and when you go home you’ve been up all night, you just want to take a nap and you’re irritable...any little incident that pops up, you blow up. (Participant 5; paramedic)

Subtheme 1.2: Secondary Traumatic Stress Symptoms

The second subtheme that emerged across interviews was STS symptoms. Sprang and colleagues, (2019) state that STS parallels PTSD; however, it also includes feeling stigmatized, decreased empathy, empathetic overinvolvement, diminished professional self-efficacy (i.e., a decrease is one’s belief in their own ability to execute an occupational task at a specific performance requirement; Cherniss, 1993), and moral distress (i.e., an emotional state that arises due to being tasked with something that is not the ethically correct action; Papazoglou & Chopko, 2017). As a corollary to STS symptoms, participants expressed cynicism towards their patients, further perpetuating the stigma that is often encountered with substance use problems and diagnoses. This cynicism was evidenced by participants’ stigmatizing perceptions and use of stigmatizing language, such as “addict,” “abuser,” and “pill-head.” Several participants viewed their patient’s behaviors and decisions as a result of a moral weakness and flawed character, rather than a result of a mental health disorder.

Feeling Stigmatized: A lot of times in our position, law enforcement, we are not looked upon as...I guess maybe wanting to help these people, but by us trying to determine who their suppliers are, prevents them from being able to maintain their addiction. (Participant 4; LEO)

Decreased Empathy: They’ll come a point in time when you will see so much stuff that you’re gonna lose your compassion...if you run a bunch of calls for overdoses and got there too late, not seeing anybody survive...that’s gonna start weighing on you. (Participant 5; paramedic)

Diminished Professional Self-Efficacy: We just kind of get to a point where we’re like ‘Is what I’m saying and what I’m doing for you, ever going to make a difference in your life?’ (Participant 10; firefighter)

Empathetic Overinvolvement: We are constantly inundated in this area with overdoses...I mean it’s overwhelming. It’s stressful, cause you feel like you personally need to shoulder the problem yourself. (Participant 4; LEO)

Moral Distress: He was having withdrawals and he had a warrant for his arrest, so I had to take him under arrest for his warrant. So, I took him to jail. The next day I get a phone call...she was like ‘well, he hung himself in jail.’ He ended up dying...after a little while, it kind of did bother me, like ‘Is that my fault,’ you know. I took him to jail but I did what I was supposed to do, because he had a warrant...In the back of your mind, you’re like ‘Well, if I had let him go, maybe he would still be alive.’ (Participant 29; LEO)

Cynicism: I guess it’s a personal thing I have, is what a waste, a lack of productivity in society...you get some money, or you went to this person, went to work, got some money. This is what you do with it? You know, I don’t have any sympathy whatsoever. (Participant 9; firefighter)

Theme 2: Variable Availability and Effectiveness of Resources for FRs

The second theme that emerged from the data was variable availability and effectiveness of resources, addressing our second aim of the study, which was to investigate FR perspectives regarding the resources available to them following opioid-related emergency calls. All participants reported having at least one available resource to utilize following an opioid-related incident (e.g., critical incident stress debriefings, chaplains, emergency helplines, peer support groups, employee assistance program). However, there was considerable variation regarding participants’ perspectives on whether these resources are effective, as well as encountering significant barriers to care. Participants identified cost, lack of structural support, and social stigma as barriers to accessing the available resources.

Subtheme 2.1: Barriers to Care

This subtheme was developed from participants disclosing that there are several barriers to accessing support and resources following opioid-related incidents. These include the department, city, and/or state not having the funding to implement new resources for the department; there is an absence of systemic support for mental well-being within their FR organization; and there is a stigma within the profession for seeking mental health services, which could impact their career negatively, as well as result in judgmental attitudes from colleagues.

Cost: Forty in-service hours. Mental health you only get four hours of that…It should probably get forty hours and extend it out through the year…I think the city wouldn’t want to pay for it. I think the financial part of it is what’s holding a lot of it back. (Participant 23; LEO)

What’s the cost? Who’s going to cover it? That seems to always be what comes up in the city and county departments. (Participant 11; LEO)

Lack of Structural Support: We were trying to get a program for us on suicide, depression, and some extra help for our mental state and we approached them, and they told us that we didn’t need that. (Participant 2; paramedic)

The agencies can say they’re supportive but sometimes they say they’re supportive but it’s like actions are gonna speak louder than words…I think this is an industry that eats its young and does so through a lack of recognition of the things that leads to burn out and attrition and mental health issues that occur and everything else. (Participant 18; paramedic)

Social Stigma: I think the only barrier is the employee taking that first initial step. And I think that first initial step is a hard one because, particularly, officers do not want to be seen as weak. (Participant 8; LEO)

A lot of cops don’t wanna tell people their problems though, cause they’re afraid they’ll get branded as a rubber gun squad. (Participant 25; LEO)

Subtheme 2.2: Pathways to Improved Care

Participants recurringly stated the need for additional resources and training and suggested ways to implement them in their current departmental system. Some of the suggestions included pre-incident and post-incident support, such as (1) creating mandatory in-person trainings that cover different mental health symptoms and how to cope with them; (2) enhancing the accessibility of resources, such as posting the mental health numbers of the EAP program in the station; (3) offering therapeutic services with a counselor or clinician; (4) developing peer support groups within the department; (5) increasing departmental mental health check-ins that go beyond debriefings; and (6) being taken off shift for a period of time following a difficult call.

It’s one of those things where I think it would be a great think to have some type of mental health training just like we have every year on the physical side of things. (Participant 8; LEO)

…you look at Phoenix, New York, Los Angeles, major departments like that, and the biggest positive thing that they’ve done for mental health for their membership is peer support. (Participant 13; paramedic)

Theme 3: Identified Roles of FRs in Reducing the Impact of the Epidemic

Finally, the last theme that emerged from the data was identified roles of FRs in reducing the impact of the epidemic. When participants were asked “how do you see yourself and your team playing a role in reducing the opioid epidemic,” the majority of the sample indicated reactive measures (i.e., offering medical aid and resources after an opioid-related incident has occurred) rather than proactive measures (i.e., working towards reducing opioid-related incidents before they have had a chance to occur).

Subtheme 3.1: Futility of Role

Participants often reported feeling that there is nothing they can do on their end to reduce the number of opioid-related incidents they have to attend to. They also revealed that the hospital staff is typically the individuals to provide the patients with resources.

But as far as, lessening the problem, I don’t know if we do. We are there to help if a problem arises, but I don’t think that we do anything to prevent it necessarily. That sounds bad but there’s just not a whole lot we can do in that aspect. (Participant 24; firefighter)

It’s like, we have one solution for all your problems, which is to take you by the most expensive means of transport and the most expensive means of care which is the emergency room to make you their problem. Then you may be there for days waiting for a referral. But you know for us it’s sorta that quick drop off. Part of it is like, “I don’t have to deal with that stuff, and I mean I got you through this. You’re not dead.” (Participant 18; paramedic)

Subtheme 3.2: Proactive Role

Although most participants expressed that they feel powerless in reducing the opioid epidemic, some participants disclosed proactive measures they have put in place, such as community outreach and working towards intercepting the drugs prior to reaching the patients.

There are things that we could do as law-enforcement agents from a proactive standpoint that we do try to do. That is criminal intervention measures. Um, try to do safety enforcement, to intercept these drugs when they are in transit from point A to point B, but that is only scratching the surface, and this is a multi-layer process. (Participant 27; LEO)

We have had several that their family was involved in opioid stuff and we’ve brought them in as junior members or some adult firefighters to get them away from that and show that there’s more to life than just that. (Participant 28; firefighter)

Subtheme 3.3: Empathetic Role

Throughout the interviews, participants disclosed their perspectives of the opioid epidemic, as well as how it has affected them and changed their roles. Still, many echoed a spirit of empathy for those they worked with and the need to carry this compassion into every call despite all challenges.

Number one, you never judge anybody. It’s real easy to say ‘Why’s someone a drug addict? Why are they using drugs? They should know better. They know it’s wrong.’ But you never know what shoes someone’s walked through. You never know what has transpired in their path to addiction. (Participant 12, LEO).

Discussion

The purpose of this qualitative study was to obtain the perspectives and lived experiences of 30 FRs attending to the opioid epidemic throughout several rural-serving counties in Tennessee. This research was conducted to fill a gap in the literature and promote an awareness of what FRs are continuously facing during this epidemic. From the semi-structured interviews, three themes emerged including (1) opioid epidemic burden on FR mental health, (2) variable availability and effectiveness of resources, and (3) identified roles of FRs in reducing the impact of the epidemic. The results highlight the adverse effects the opioid epidemic has had on FRs and the need for additional resources to support these overloaded frontline workers.

The research findings in this study indicate that FRs are recurringly faced with uncertainty when responding to opioid-related incidents, especially when attending to the repercussions of the opioid-related incidents on children and family members. As a correlate of these difficult circumstances, FRs are exhibiting varying degrees of psychological repercussions (i.e., PTS and STS symptoms). In particular, symptoms of intrusion, avoidance, negative cognition and mood, and hyperarousal were endorsed by participants as being related to the compounding effects of continuously responding to opioid-related incidents. Although prior research has not critically examined the mental health symptoms among FRs combatting the opioid epidemic, our results align with previous findings of increased PTS symptoms among FRs combating other epidemics, such as the HIV/AIDs epidemic (Thompson & Marquart, 1998) and the COVID-19 pandemic (Wright et al., 2020).

Furthermore, the current study is the first to look at STS symptoms among FRs and finds that participants are experiencing moral distress, decreased empathy, diminished professional self-efficacy, stigma, and empathetic overinvolvement. Previous research has investigated vicarious trauma and compassion fatigue among this population (Greinacher, et al., 2019). Although these are often interchanged in the literature with STS, they differ from one another in definition and symptomology (Sprang et al., 2019). Thus, future research should seek to replicate and expand on the current study’s findings of STS symptoms, as this may help identify mild to subclinical levels of functional impairment that do not meet clinical significance for a PTSD diagnosis (Sprang et al., 2019).

In addition to FRs experiencing psychological symptoms, they are also experiencing emotional repercussions as a result of responding to opioid-related incidents. While FRs maintain empathetic views towards their patients and remind themselves of why they got into the profession, they are also feeling futility to their role as they continuously respond to this population. These feelings have translated to increased cynicism, further perpetuating the stigma patients face. These findings are consistent with previous studies, suggesting that responding to opioid-related incidents often leads to negative feelings of frustration and cynicism (Pike et al., 2019). However, some FRs have also embraced a proactive role which they may realize as an adaptative coping strategy. Previous research has documented that adaptive coping techniques (e.g., Kirby et al., 2011) result in posttraumatic growth and increased well-being among FRs (Arble & Arnetz, 2017).

Based on the findings of our analyses and direct requests from participants, there is a need for resources to help FRs mitigate the preceding consequences of responding to opioid-related incidents. The analyses revealed that although participants receive technical training (i.e., medical trainings, such as learning to provide basic life support) and are provided with some resources to assist in dealing with the repercussions of the opioid epidemic (e.g., debriefings, chaplains, peer support groups, mental health professionals, helplines), participants often disclosed considerable variation on whether or not these resources are effective. In addition, they reported facing barriers to accessing resources as a result of cost, lack of structural support, and social stigma.

Of note, the latter barrier was viewed by participants as due to their profession’s culture of stoicism hindering one’s ability to seek mental health support and services. Participants often disclosed that there is a fear that seeking support would impact their career. Overall, these barriers align with previous research findings that FRs are at a decreased likelihood of seeking mental health services due to structural barriers and stigma (Jones et al., 2020; Stanley et al., 2017). Such findings suggest that efforts should be dedicated to increasing the accessibility of resources within this profession.

In addition to the barriers FRs are facing when accessing resources, they also disclosed possible pathways to improved care. Some of the pre- and post-incident resources participants suggested include mandatory in-person mental health trainings, counselors and therapists, peer support groups, and mental health check-ins. The number of resources participants disclosed needing is indicative of what FRs are increasingly faced with and how responding to opioid-related incidents is affecting them. Furthermore, the lack of adequate resources may be putting FRs at risk for additional stressors and exacerbating mental health symptoms. Therefore, it is imperative for departments, cities, and states to increase the availability of resources to further assist FRs in coping with the repercussions of the opioid epidemic (Andersen et al., 2015; Compton et al., 2014; Szeto et al., 2019).

Finally, the last theme that emerged suggested that many FRs exhibit low self-efficacy related to reducing the impact of the opioid epidemic, including not knowing of any resources to provide patients and not having enough time to make a difference due to increased service utilization. These factors offer insight into the impact of the opioid epidemic on FRs, including their sense of powerlessness, further burdening them. As a result of FRs continuously encountering persons who use drugs, they serve as an important bridge between the patient and community resources, such as local rehabilitation centers. By offering such resources to patients, the number of overdose deaths, emergency call volume, and state costs (i.e., it costs less to connect patients with services than to place them in the criminal justice system) may in turn decrease (Police Executive Research Forum, 2016). Thus, it is suggested that FRs may benefit from engaging in proactive behaviors and manifesting collaborations within their community to assist individuals who use drugs.

Limitations

This present study has features that limit inferences. First, the sample is not random and represents those who self-selected to participate. Additionally, the sample was not diverse in terms of gender, ethnicity, sexual orientation, and geographic region (i.e., all participants came from rural-serving counties). Furthermore, given that participants have been exposed to significant trauma unrelated to the opioid epidemic, they may have over-reported their symptomology despite efforts from the primary investigator to frame the questions in a way to elicit responses only involving opioid-related calls. It is also unknown to what degree previous trauma exposure in this population affects their current ability to deal with the opioid epidemic and how these experiences shape their coping mechanisms to be adaptive or maladaptive during the present study.

However, considering the study’s sensitive nature and the qualitative methodology of the investigation, participants may have underreported the repercussions they are facing. Since participants were not anonymous to the primary investigator, they may have felt uncomfortable answering questions in a forthright manner. Despite the preceding limitations, the study provides novel insights into the impact and burden the opioid epidemic has elicited on FRs. It would be of benefit for future research efforts to investigate whether similar findings would manifest among different FR demographics in order to increase the validity of the current study’s findings.

Implications

The results of the present study suggest that FRs are experiencing a multitude of negative consequences due to their work on the frontlines of the opioid epidemic. Namely, PTS and STS symptoms were found among participants of this study giving future researchers an opportunity to examine if clinically diagnosable levels of PTSD can be found among this population due to their involvement with the opioid epidemic. Compounding the repercussions of repeatedly responding to opioid-related incidents, the lack of adequate resources may be putting FRs at risk for additional stressors and exacerbating mental health symptoms. FR departments, government entities, and clinicians should be aware of these consequences in an effort to be better-informed and create trainings, as well as resources, that highlight the effects of the opioid epidemic and ways in which the consequences can be mitigated within the FR community.

However, given the stigmatizing attitudes FRs often hold towards mental health concerns within their profession, it is important to note that resources provided to them should address concerns of confidentiality and privacy, while meeting the demands of shift work. Connecting them with mental health resources where a diagnosis is not put on record, a clinician who specializes in providing trauma-informed care specifically for FRs, and a clinic whose hours of operation are flexible to meet the demands of shift work are all steps in the right direction. Additionally, departments can decrease stigmatizing attitudes by providing mental health trainings to their FRs and changing the narrative within their profession that having mental health concern is not a sign of “weakness” or “failure.”