Massachusetts OEND

Case Study

Massachusetts creates a comprehensive statewide naloxone distribution program that is fully supported by the Department of Public Health after years of work by harm reductionists and concerned community members.

Massachusetts DPHOverdose Education and Naloxone Distribution (OEND) in Massachusetts is the result of joint public health system and community advocate efforts fueled by unacceptable levels of death and sorrow.  OEND efforts began in the late 1990s by a few committed activists who were working with injection drug users in Massachusetts who were tired of seeing their friends, family members and program participants die from preventable overdoses. They obtained naloxone from some colleagues in the harm reduction movement and began informally distributing it to drug users. They collaborated with needle exchange staff at a Massachusetts AIDS Service Organization to present the need for an OEND program to agency leadership and public health officials at the city and state level. At this time, there was little interest in adopting what was seen as a controversial and untested intervention, so the activists continued their distribution of naloxone without “official” approval or oversight from a medical professional. The harm reductionists who were distributing naloxone recognized that while they were putting life saving tools into the hands of drug users, they were also putting programs and participants who distributed or carried naloxone at risk for legal complications. They began collecting basic information about the number of people that they distributed naloxone to and the number of reported overdose reversals and compiled this data into a short report and submitted it to a friend who was working with the Boston Public Health Commission. She used the informal “data” to create a proposal for the city of Boston to begin providing naloxone distribution at the city needle exchange.

By this time in late 2005, there was a growing number of people and agencies interested in formally incorporating OEND into state-funded HIV prevention programming because of their contacts with injection drug users. This was prompted in part by an intense negative media campaign about drug users–particularly one who was photographed in the process of overdosing and dying–which provided an important spark.  Additionally, Massachusetts was experiencing a rise in overdose deaths, beginning in the early 2000s and rising steadily over the years to unacceptable levels.

BY 2006, the Board of the Boston Public Health Commission, the City of Boston’s Health Department, approved a pilot program which consisted of training active IDUs in how to avoid, recognize and respond to a drug OD and began the distribution of nasal Naloxone to enrollees.  A year later, the board was presented with the results of this initial work and approved the program unanimously. Thus it became an “official” program.

This approval for the program was accomplished with support from the Mayor of Boston, community advocates, medical professionals and drug users. The regulation issued by the City of Boston named staff “special employees” for whom the City assumed legal liability for activities related to the overdose prevention pilot program that included naloxone distribution, which was operationalized at the needle exchange program.  This included the medical staff under whose license the naloxone was provided and the nonmedical staff who provided the overdose education and distributed the naloxone.  By early 2007, the Cambridge Public Health Department had also begun OEND activities at the Cambridge needle exchange.  The Cambridge Public Health Department provided a nurse for several hours per week who was operating under the orders of the medical director to distribute naloxone to anyone at risk of an overdose who wanted training and a naloxone rescue kit.  This design was considered regular medical care and special public health regulations were deemed unnecessary.

In 2007, the year with the highest ever recorded number of fatal overdoses in MA, the leadership of the Boston Public Health Commission had moved up to the Massachusetts Department of Public Health (MDPH) and brought with them their interest in and experience with OEND.  That year, MDPH established a plan to address overdose including expansion of buprenorphine access, community grants to address overdose prevention, and expanding OEND to include four additional agencies beyond the Boston and Cambridge needle exchanges.  The OEND project was established based on a written statement from MDPH legal counsel and the Director of the MDPH Drug Control Program that MDPH Drug Control regulations allow DPH to conduct pilot projects to determine whether a change in regulation would be warranted. The model that was outlined includes one statewide medical director who issues a standing order for the naloxone to be distributed by approved overdose prevention trainers in the community.

The MDPH OEND program was implemented as a joint collaboration between the MDPH Commissioner’s Office, the Office of HIV/AIDS and the Bureau of Substance Abuse Services. The program started in HIV Prevention programs in the community and has been expanded to include substance abuse treatment programs and hospital Emergency Departments.

By 2011, there were eight agencies operating in 12 communities and one training organization that works with statewide substance abuse treatment programs providing OEND services.  Together, these agencies have trained more than 10,000 drug users, friends and families of drug users, service providers, and first responders about how to prevent and manage an overdose- nearly 1,200 reports of the naloxone being used to reverse an overdose have been received so far.  There are plans for expansion in FY2012 to new communities and settings in Massachusetts.

Elements of the Massachusetts OEND program:

  • Supported and funded by the Massachusetts Department of Public Health (MDPH) Bureau of Substance Abuse Services and in-kind contribution of existing staff time;
  • Operating under existing MDPH Drug Control Regulations;
  • Medical Director issues standing orders for trained nonmedical public health workers to train and distribute nasal naloxone to potential opioid overdose bystanders;
  • Services provided by staff of agencies with existing Office of HIV/AIDS or Bureau of Substance Abuse Services contracts and partner organizations;
  • Agencies opt-in and do not receive additional funding;
  • MDPH provides nasal naloxone, mucosal atomizers, and educational materials to approved agencies for distribution;
  • Potential overdose bystanders are anonymously enrolled using a code based on a memorable formula and able to refill naloxone rescue kits for any reason at any agency location;
  • Services are delivered at needle exchange programs, HIV prevention drop-in centers, homeless shelters, methadone clinics, detoxes, office-based medical care, emergency departments, residential drug treatment programs, community meetings, street outreach, home delivery, and by other arrangements.
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