Module 3: Take-Home Naloxone Program Development
Today, there are more than 300 programs doing community-based naloxone distribution. Most of these programs are run out of syringe access or other harm reduction programs, but take-home naloxone programs are expanding to physician’s offices, drug treatment programs and hospital emergency rooms.
Harm reduction programs were a logical first home for take-home naloxone programs because they already work in close collaboration with people using drugs. Harm reduction programs have a direct source of knowledge from people who use drugs who have overdosed or witnessed overdose, including insight into how first responders and emergency rooms are treating overdose victims and changing drug trends that impact overdose risk.
It is also appropriate and necessary to implement take-home naloxone programs in a variety of other settings with access to individuals who are, or could be, at risk for overdose. Take-home naloxone programs are also invaluable for potential bystanders and witnesses to overdose, like family members or loved ones of people who use drugs.
This section will outline important considerations when planning a take-home naloxone program including community engagement, legal considerations, the role of medical professionals and special considerations for implementation within different venues.
Community Assessment, Outreach and Engagement
Engaging in a community planning process is an important step in creating a take-home naloxone program. It is important to tailor your overdose prevention work to the community you work in and, whenever possible, gain community buy-in. One of the first and most important steps is to gather information about overdose in your community. See our interactive checklist on understanding overdose in your community below.
Some communities are able to collect this information using formal sources, such as the Medical Examiner’s office; however, in some communities it can be more difficult to get this information. It is helpful to tap into the knowledge of community members who are already somehow engaged with those most at risk of overdose, and also to better understand and assess what is currently known about local overdose trends.
These groups may not only be interested in supporting future work on overdose prevention, but they may also have valuable information about current and past overdose risks in the community. If you do not already work with people who use drugs, familiarizing yourself with service providers who do can facilitate the linkage of your program to those most at risk for overdose. Reaching out to these stakeholders will help make your take-home naloxone program more relevant and better integrated with the community.
Reviewing Existing Data
Gathering both qualitative and quantitative data will be helpful in making a case for local take-home naloxone programs and will also help you target your services to those most at risk. Similar to the list of potential community stakeholders, possible sources of local data and information include the following:
- City and State Health Departments
- Community Needs Indexes (where applicable)
- Emergency Medical Services (Ambulance, Fire)
- State or City Offices of Vital Records
- Medical Examiner or Coroner’s Offices
- Local emergency rooms
- Police reports of drug arrests
- Methadone programs
- Hospital-based and private detoxification programs
- Local drug treatment centers
- Pharmacies and local health-care clinics
- HIV/AIDS service organizations and other community-based organizations
- Syringe exchange programs in other cities and states
You can also consult national data sources if it is proving difficult to get local data. Some great sources of national data on overdose are the Centers for Disease Control (CDC) and the Substance Abuse and Mental Health Services Administration (SAMHSA).
Collecting Original Data
Oftentimes, reviewing existing data on overdose trends reveals a lack of information on the subject. For this reason, it is important to collect new data related to the issue.
Methods for collecting original data include:
- Key informant interviews
- Field observation
- Focus groups
During interviews, focus groups, and surveys, it is helpful to ask about:
- Witnessing overdose
- Firsthand experiences of overdose
- Types of drugs commonly available and consumed locally
- Drug purity
- Common modes of administration of these drugs
Understanding Overdose in Your Community
- Who is overdosing? (i.e. age, race/ethnicity, gender, etc.)
- What drugs are people taking when they overdose?
- How are people taking drugs when they overdose? (i.e. injecting, snorting, orally)
- Where is overdose occurring? (i.e. which cities and neighborhoods)
- In what settings are people overdosing?
Key Elements of a Community Assessment Process
- Reviewing existing data and policies
- Collecting original data
- Identify stakeholders. Stakeholders include, but are not limited to:
- People who use drugs
- Friends and family of people who use drugs
- Syringe access / needle exchange programs
- First responders (fire departments, EMS, etc.)
- Homeless shelters
- Drug treatment providers
- Jail discharge planners
- Housing programs
- HIV prevention programs
- Health departments
- Hospital emergency departments
- Pain clinics
- Community Health Centers and Health Care for the Homeless Clinics
- Parent support groups
2012 Case Study
Chicago Recovery Alliance | Chicago, Illinois
Dan Bigg from CRA talks about how the first take-home naloxone program in the US began.
Chicago Recovery Alliance (CRA) started harm reduction (HR) outreach in January 1992 and, through respectful collaboration with people injecting drugs, has grown to become one of the larger HR programs in the world to date. Starting in a state where it was illegal to purchase or possess a syringe without a prescription, our work’s research component exempted CRA and our participants from the laws against syringe and other injection equipment prohibitions. As we’ve grown, we have met regularly and formally with our participants in what we call Community Advisory Groups (CAG) — composed of a diverse group of people injecting in a geographically limited area — paying people for their expertise and having a good meal at each CAG meeting. CAGs have always informed both the initiation of and ongoing feedback about our work. If CRA owes anything to its successes it is listening to the feedback given by CAGs! As our participants report other needs and interests we respond similarly — such as making viral hepatitis prevention the ‘gold standard’ of safer injection, including integrating HAV/HBV vaccination into our work, and addressing opiate-related overdose prevention. As early as 1995, CRA made our first t-shirt that had a list of HR options on the back, including: “Keep Narcan Around.”
It was May 4, 1996 and one of our founders, John Szyler (who had created our philosophical touchstone: “any positive change”) died of a heroin overdose. He left us to not only grieve his loss, but also to use his death to motivate — you guessed it — another positive change in helping people prevent overdose by teaching about it and making naloxone, the decades proven opiate overdose antidote available to our participants. In the fall of 1996, after sadness turned to desire for action, some MD friends and myself started naloxone training and distribution to select CRA participants. Overdose was, and is, the number one cause of premature death among our participants and people were delighted about having this resource available to them. For those participants who had heard about naloxone, it was generally regarded as kindly as garlic might be to a vampire. Most experiences with naloxone up to that point were after abuses at the hand of an emergency medical provider who shot 2 mg intravenously into a person who had overdosed and subsequently fought with them as they exploded out of the emergency room or ambulance in serious withdrawal. Following HR practice, we sought out medical help that valued and respected life and human rights. Shawn DeLater, an emergency room physician and Sarz Maxwell, an addictionologist, were our first medical care providers ready and willing to put a healthy, lifesaving touch on reversing opiate-related overdose with effective and humane intervention. From 1997 to 1999, our program expanded slowly and steadily in Chicago, and at our insistence, the Drug Policy Alliance held the first Opiate Overdose Conference in Seattle with international presenters in early 2000.
In January 2001, CRA rolled out its first overdose training for all staff, interested volunteers and participants and incorporated naloxone distribution to all sites and contact points CRA operates. At this time, we also posted materials on our website for any other program to use. Through spreading the word within the HR community about the effectiveness of naloxone distribution, other programs in the US began to start distributing naloxone by the late 1990s and early 2000s.
One consistent hurdle in development of our program was that we first tried to err on the side of caution and provide a lengthy training to participants. After the program had been going for a while we realized that getting good overdose info (focused on maintaining airway and breathing) and naloxone to people in sufficient economy was essential and we slowly distilled the essential information down to a few essential points which we called SCARE ME (see page 19).
In 2010, through collaboration with the AIDS Foundation of Chicago and other HR programs in Illinois we came to enact a new law supporting effective overdose prevention work in our state (20 ILCS 301/5-23) which exempts both prescribers of naloxone and lay persons who try to revive a person with naloxone. Since then, many other programs in Illinois have started providing naloxone.
Our approach is based on forming harm reduction relationships with participants; listening for needs/interests and acting accordingly; and consistently providing as many options for positive change as possible. Through August 2011 we have provided 22,010 overdose prevention encounters and received 2,720 reports of peer opiate-related overdose reversal!
SCARE ME is an acronym for:
Evaluate the Situation
According to Scott Burris, JD, of Temple University Beasley School of Law, “In the US, naloxone programs fall within the scope of normal medical practice and no specialized legislation is required for them to operate.” Prescribing naloxone to opioid users who are at risk for overdose is a simple and inexpensive harm reduction measure that has the potential to significantly reduce mortality from opioid overdose. Although some physicians in the US may be discouraged from distributing naloxone due to legal concerns, legal analysis conducted by Burris finds that the legal risks are low. Prescribing of naloxone in the US is fully consistent with state and federal laws regulating drug prescribing.4
Many successful programs have moved forward under the existing legal framework and, further, have advocated with health departments or state legislatures for funding or additional political support. Advocacy has included specific legislation to reduce physicians’ fear of liability, to protect third-party administrators (the actual user of the naloxone), to protect bystanders who call 911 from prosecution, and to provide government funding.
The DOPE Project | San Francisco, California
The DOPE Project borrows from their friends, gains the support of the city public health department and secures funding and a doctor to support their existing overdose prevention work.
The DOPE (Drug Overdose Prevention and Education) Project was built on a strong legacy of harm reduction efforts in San Francisco as well as other cities (Santa Cruz, California; Chicago, Illinois), states (New Mexico), and countries (Australia, England, Canada).
In 1993, youth outreach workers in San Francisco first distributed overdose prevention education flyers developed by the Santa Cruz Needle Exchange in California. In 1998, in response to increasing fatal overdoses among young IDUs in the Haight Ashbury district, syringe exchange street outreach workers in San Francisco began conducting monthly overdose prevention trainings targeting young IDUs. Education materials were adapted from materials developed in Santa Cruz, California, Chicago, and Australia—early innovators in overdose prevention.
Using supplies from peers in the harm reduction community, street-based syringe exchange workers in San Francisco began incorporating training in naloxone into their monthly overdose trainings for young IDUs. What began as a community-led response among outreach workers and researchers, soon gained institutional support from local public health and substance abuse treatment officials. Research combined with policy advocacy and direct service work made the DOPE Project possible by getting buy-in from the local health department, people who use drugs and HIV researchers, harm reduction organizations and people who utilize those services.
Research played a critical role in building the case for overdose prevention interventions in San Francisco. In the early-1990’s, empirical evidence among HIV and drug use researchers and prevention workers suggested that IDUs, while targeted for HIV prevention, were instead dying of heroin-related overdose. However, little research had been done to assess the incidence of fatal and nonfatal overdose among IDUs in the U.S. Research and pilot overdose prevention projects conducted in San Francisco by the University of California San Francisco (UCSF)’s Urban Health Study throughout the late 1990s and early 2000s were instrumental in demonstrating the need for overdose prevention, the overdose risk experienced by people who use drugs, and the likelihood that overdose prevention interventions could be successfully adopted.
In July 1999, the San Francisco Treatment on Demand (TOD) Planning Council tasked a diverse committee with developing recommendations for a response to the city’s “heroin epidemic.” The Heroin Committee comprised researchers, clinicians, drug treatment providers, outreach workers, social service providers, people who use drugs and others who developed recommendations for addressing heroin-related issues in San Francisco, including overdose prevention. Several of the Heroin Committee’s recommendations were funded and implemented, including a citywide overdose awareness campaign. The campaign featured billboards, bus shelter ads, and free, 20-minute phone cards, which were distributed by programs serving IDUs with pre-recorded messages encouraging people to “fix with a friend.”
As DOPE Project founder Rachel McLean noted, “It’s about being entrepreneurial. You knock on lots of doors and whichever opens, you walk through.” Rachel had written a school paper on the problem of overdose for a public health class, and then written a follow-up paper describing a programmatic response to the problem, which she summarized in a one-pager she gave to the Heroin Committee. Two years later, the public health department had some spend-down money at the end of the fiscal year (as health departments frequently do in June, which can be an excellent source for small and pilot projects), and staff remembered her proposal and asked her to start the overdose prevention project she had recommended.
In December 2001, the TOD planning council allocated $30,000 in city seed funding to establish a comprehensive overdose prevention program to put the committee’s remaining, unfulfilled overdose recommendations into practice and in January 2002, The DOPE Project began with a team of eight overdose trainers conducting trainings on overdose recognition, management, response, and prevention for program participants and workers of syringe exchange programs, homeless shelters, drop-in centers, drug treatment programs, pretrial diversion programs and other venues serving people at risk for drug overdose. The curriculum, which was adapted from materials from the Santa Cruz Needle Exchange, Chicago Recovery Alliance, San Francisco Needle Exchange, and other programs, included rescue breathing, safely calling 911, overdose myths and prevention, but did not include naloxone administration. Trainings typically lasted 30-45 minutes for program participants and 1.5 hours for providers.
In 2003, researchers from the Urban Health Study presented the findings of their naloxone pilot study conducted in 2001 to the Director of the San Francisco Department of Public Health (SFDPH). The findings of the naloxone pilot study, along with an article by Scott Burris on exploring the legal implications for physicians of prescribing take-home naloxone to heroin users, proved instrumental to SFDPH’s decision to give the green light for a citywide take-home naloxone program in San Francisco.
In late 2003, the DOPE Project began providing naloxone by prescription in collaboration with Dr. Josh Bamberger, medical director of the SFDPH’s Housing and Urban Health program. DOPE trainers provided the overdose prevention and response education, and the Nurse Practitioner at the site would complete a “clinical registration” form with the person, and sign off on the naloxone prescription. In June 2005, the DOPE Project became a program of the Harm Reduction Coalition, and in 2010, the city changed its policy to allow DOPE trainers to distribute naloxone directly under a standing order without a medical provider present.
Venues and Tips for Different Settings
This section adapted from the work of Maya Doe-Simkins, Alex Walley and colleagues for their “Notes from the Field (temporary title)” Overdose Prevention Manual.
Naloxone programs can be implemented effectively wherever they may reach individuals at risk for overdose, or potential bystanders. That being said there are some venues that are particularly well suited to implement take-home naloxone programs, including:
- Syringe access/harm reduction programs
- HIV/AIDS service and prevention organizations
- Drug treatment programs
- Jail and corrections
- Parent and family groups
- Health care settings and pain management clinics
This is not to suggest that these are the only places where overdose prevention programs are needed, but they are good starting points. Overdose prevention and education should be available in a variety of settings, to a variety of different people who may be potential bystanders or witnesses to an overdose. People who use drugs, their families and friends and staff of programs are all potential lifesavers in an overdose situation. Additionally, some first responders (Fire, EMS) could benefit from a more in-depth discussion about the risk factors that contribute to overdose as well as compassionate strategies for dealing with overdose in the community.
Syringe Access/Harm Reduction Programs
Chicago Recovery Alliance, a harm reduction and syringe access program (SAP), was the first program in the US to start distributing naloxone to people who use drugs in 1996. Since then, many other SAPs in the US have started take-home naloxone programs while others provide overdose prevention trainings, workshops, and educational materials at their exchanges. It should become standard practice to include overdose prevention in syringe access operations since overdose is the single most common cause of death among people who inject drugs (PWID) (more than HIV and hepatitis C).
HIV/AIDS Service and Prevention Organizations
Overdose prevention and response are necessary components of quality HIV/AIDS programming for people who use drugs (PWUD). Some programs that provide services to people living with HIV/AIDS may not have funding to provide syringe access (the most obvious way that PWUD are engaged in HIV prevention) but this does not mean they do not serve people who use drugs. HIV case management and housing programs, HIV testing sites and health care clinics that specifically treat people living with HIV/AIDS are all ideal places to provide take-home naloxone and overdose prevention. In the publication, Why Overdose Matters for HIV, Curtis and Dasgupta describe seven reasons why it is critical to link HIV services with overdose prevention and education:
- Overdose is a significant cause of mortality among people living with HIV. Overdose often greatly exceeds HIV and other infectious diseases as a cause of death among people who inject drugs.
- HIV infection is associated with an increased risk of fatal overdose, due in part to systemic disease and liver damage associated with HIV infection. HIV care and treatment providers should therefore prioritize providing overdose prevention support to their participants who use drugs.
- Overdose prevention services connect people who use drugs to HIV prevention, drug treatment, primary health care and other basic services. By expanding the breadth of care and support and addressing the priorities of people who use drugs, HIV prevention services may expand coverage and more effectively fight the HIV epidemic.
- Overdose prevention empowers people who use drugs and who are at risk of acquiring HIV. Overdose education and naloxone distribution put powerful tools in the hands of people who use drugs, much as syringe exchange enables people to take charge of their health
- Overdose may exacerbate HIV-related disease. Nonfatal overdose is associated with a number of disease sequelae, including pneumonia, pulmonary edema, acute renal failure, rhabdomyolysis, immune suppression, physical injury, and other conditions.
- Many of the same policies that increase risk of HIV infection among people who inject drugs also increase the risk of overdose; addressing overdose risk can impact HIV risk. State policies that criminalize and incarcerate people who use drugs or prioritize abstinence-based, often compulsory, drug treatment are well documented to increase the risk of HIV infection and the risk of overdose.
- Overdose is a serious concern among people living with HIV who use drugs. Virtually any survey of people who inject drugs shows that large majorities have both experienced and witnessed overdose, and that a significant proportion have experienced multiple overdoses in their lifetime.
For full text and references, please see The Eurasian Harm Reduction Network publication.9
Drug Treatment Programs
Take-home naloxone programs fit with a variety of types of drug treatment modalities, including medication for opioid use disorder (MOUD) programs like methadone and buprenorphine clinics, residential treatment facilities, short-term inpatient detoxes and outpatient clinics. Drug treatment providers have a unique opportunity to reduce unintentional overdose deaths because they have access to people at risk for overdose and the responsibility of ensuring the health and safety of their participants.
People who use drugs and are engaged in treatment may have lower risk for overdose while in treatment, but are at extremely high risk of overdosing if they begin using again after a period of abstinence or reduced use. Integrating overdose prevention and education messages into treatment planning, “relapse prevention” groups and most importantly, discharge planning does not encourage reuse or drug use, but instead offers practical, honest information and resources to someone who may begin using again. If it is not realistic to implement a take-home naloxone program, it is important to refer people to their closest take-home naloxone program upon discharge.
In some places in the US, drug treatment programs have embraced this idea and have begun giving participants of inpatient detoxes who are not going on to further treatment a naloxone kit upon discharge. Some methadone maintenance programs include overdose prevention and naloxone prescriptions as part of the intake process. Some residential treatment programs overdose prevention, education and response workshops as part of their rotating group schedule. In New York State, the Offices of Alcohol and Substance Abuse Services offers CASAC/CPP/CPS credit hours for addiction medicine professionals who participate in an online course about overdose prevention.
Methadone and buprenorphine (Suboxone®) programs are ideal places to implement overdose prevention and take-home naloxone programs. According to a 2007 SAMHSA report, the majority of methadone overdose deaths are associated with use of the drug for the treatment of pain rather than addiction, but methadone clinics are great places to implement overdose education as a way of reducing overdose deaths and showing patients their lives and lives of their family and friends are important to the clinic.
Most deaths associated with methadone can be described by one of three scenarios:
- Accumulation of methadone to toxic levels at the start of treatment for pain or opioid use disorder (i.e. the induction phase).
- Misuse of diverted methadone at high doses and/or by individuals who had little or no tolerance to the drug.
- Synergistic effects of methadone used in combination with other CNS depressants, such as alcohol, benzodiazepines, or other opioids.
Medication for opioid use disorder (MOUD) patients who are in the induction phase, who have co-occurring morbidities or polysubstance use are at higher risk for overdose. MOUD patients whose treatment ends abruptly, or who begin to decrease their dose of methadone may supplement with other opioids to relieve withdrawal, putting them at high risk for overdose. Finally, MOUD patients are important bystanders and potential users of naloxone because they may still know many individuals or family members who are using.
Here are some possible scenarios for incorporating overdose prevention into a treatment setting. In order from simplest to most thorough.
- Clinic staff refer patients to the closest overdose prevention program/take-home naloxone program for training and naloxone as part of their treatment plan;
- Take-home naloxone/overdose program staff regularly visit the treatment clinic to provide on-site training and to distribute naloxone;
- Clinic staff provide overdose prevention training and subsequently refer trainees to the closest take-home naloxone program for naloxone;
- Clinic staff provide both overdose prevention training and distribute naloxone on-site.
Providing Overdose Prevention Training with Drug Treatment Program Staff
If you are hoping to provide overdose education to participants in drug treatment, it is usually a good idea to offer training for program staff first. Typically, once staff are trained and get comfortable with the training and the topic, they become open to having their program participants trained. Sometimes this happens immediately, while other times it requires a prolonged process to build comfort and acceptance and to demonstrate appropriateness. Harm reduction interventions have not always been accepted in more traditional treatment programs, and drug treatment providers may benefit from a discussion about the perceived ethical dilemma of providing overdose prevention, education and naloxone rescue kits to individuals in drug treatment. Questions that are likely to come up include:
- Will overdose prevention/naloxone training support continued/more use?
- What kind of message does it send to people in treatment?
See the interactive guide: Tips for Training Drug Treatment Program Staff below
Providing Overdose Prevention Training with People in Drug Treatment
When providing training at another agency, it is vital to be mindful of and respect the confidentiality of participants, including among host agency staff. For example, although a methadone counselor may have arranged for a group or training to take place, patients that attend the group could suffer negative outcomes if their counselor learns about their polydrug use from discussions within the group. It is best to either avoid situations where someone may disclose this kind of information, or have such conversations in private without counselors present.
The trainer should approach groups by first asking what they know about each topic, as opposed to simply telling them about each topic. This allows for a more interactive session and recognizes that all participants come to the session with existing knowledge on the subject: failure to acknowledge this can be both boring and insulting to training participants. Under these circumstances, you’re likely to find that groups will generally run themselves.
If participants (or staff of the treatment program) express discomfort about discussing drug use or relapse, try reframing the training as “how to save a life” and discuss the possibility of being around others, like family or friends, who may continue to use and who may be at risk of overdose. While this may seem insincere or feel like a compromise, it is a legitimate way to discuss overdose prevention and response with participants who may otherwise be unwilling to engage. Either way, they will receive information that they can apply to their own experience if they begin using again at any point after treatment.
Tips for Training Drug Treatment Program Staff
- Explain the legal basis for the project and be prepared to field questions.
- Encourage the agency to develop its own internal policy about overdose prevention and naloxone. Bring a copy of an existing agency policy to use as an example.
- Discuss any possible risky environments or situations unique to their program, i.e. are there locking bathrooms, are people in rooms alone?
- Discuss strategies to ensure that residents/guests/program participants feel comfortable and safe reporting overdose or accessing naloxone rescue kits to manage the overdose.
- Describe how overdose prevention conversations enhance therapeutic relationships and build trust with program participants.
- Explain that there is no evidence that discussing overdose prevention and response with individuals in drug treatment results in reuse.
- Explain that while naloxone is provided to treatment program participants, it may also be used to save the life of someone else (i.e. peers or family members). Telling a person in treatment that they have the potential to save a life is a very positive message, particularly for those new in treatment that may be struggling to feel good about themselves.
- All groups should be reminded that using naloxone as punishment (i.e. — administering naloxone to someone who is not experiencing an overdose or administering too much naloxone) will be counterproductive.
2012 Case Study
Clean Works of The Grand Rapids Red Project | Grand Rapids, Michigan
A needle exchange program in Michigan takes action to expand access to naloxone.
In Kent County, Michigan, overdose is currently the leading cause of unintentional injury of all people aged 21-65, yet it is not an issue that is addressed locally by public health. People are dying in Kent County, but they are dying largely silent deaths.
At the Clean Works program of the Grand Rapids Red Project, we view this as unacceptable. Overdose fatalities, specifically opiate overdose fatalities, are preventable. We decided that we should do something about this as an organization, and as a group of people concerned with the health of people who use drugs.
In October of 2008, we began partnering with a local doctor to provide participants of our syringe exchange program with access to the life saving medication naloxone and the knowledge and skills to use it to successfully intervene in opiate overdose situations.
Prior to this point there had been limited naloxone access within the City of Grand Rapids, but more was needed to make an impact in the rapidly rising death toll from opiate overdose fatality. Michigan does not have specific legislation dealing with naloxone and overdose programs, so the same laws apply as with any prescription medication.
So, in October of 2008, we began providing comprehensive overdose prevention and intervention trainings using the SCARE ME protocol developed by the Chicago Recovery Alliance. A lot of research and work has gone into reducing overdose fatality in other cities and by other organizations; instead of reinventing the wheel in Grand Rapids, we borrowed it from other organizations.
In Grand Rapids, we operate a fixed site syringe exchange program 3 days a week. Overdose trainings are available on a walk-in basis for free anytime we are open. We are located in the Heartside neighborhood in downtown Grand Rapids. The overdose mortality rate in the neighborhood in which we operate is 45 times the average rate in Kent County. The neighborhood is dominated by shelters, soup kitchens and low-income residences, and has seen a large rate of gentrification in the past few years. A large proportion of our program participants come from the area in which we operate, but we also receive program participants from many miles away as we are the only syringe exchange program in the Grand Rapids area. Through our overdose prevention program, we talk with our program participants about recognizing overdoses, the importance of rescue breathing, calling 911, and how to intervene in an overdose. Program participants are provided with access to naloxone hydrochloride.
Almost immediately after starting this program, we began receiving reports of people reversing overdoses because of the knowledge and the tools we had the opportunity to put in their hands. Through August of 2011, we have had the opportunity to facilitate 209 trainings, and these trainings led to 64 reported overdose reversals.
The success of this intervention cannot be denied on an individual level. Anyone who has experienced a friend turning blue, knocking on death’s door right next to them, and not knowing what to do—contrasted with having the tools, the knowledge, and the ability to save that friend’s life—knows that this intervention works. We have 64 reported reversals to show the strength of this intervention on an individual level. What we also like to see is our interventions working on a community level. Shortly after starting to provide overdose prevention and intervention trainings in Grand Rapids, cumulative overdose fatalities began to stabilize. After increasing almost four-fold in the past fifteen years, overdose fatality stopped increasing, and as of 2010 it actually started decreasing in Kent County.
Training people who use drugs on how to intervene in overdose situations works. Providing people with the knowledge and tools necessary to save lives, saves lives. People who use drugs are the true first responders in most overdose situations, and it’s past time we treated them as such.
Jail and Corrections
Individuals with a history of drug use who are leaving jail or prison have a great likelihood of overdosing in the first 2 weeks following discharge. Correctional settings are great places to provide overdose prevention information and ideally, naloxone prescription at the time of discharge. Overdose prevention groups can be provided to individuals in treatment programs in prison/jail, on open tiers where educational groups are offered or in classrooms. It is also beneficial to work with probation offices, drug courts and pre-trial diversion programs to provide overdose prevention education and when allowed, naloxone prescription.
As a program or individual providing harm reduction services, it can be challenging to get access into the correctional system to provide overdose education, but several programs across the country (in San Francisco, Pittsburgh, New York City, Baltimore, Massachusetts, Rhode Island and several facilities in New Mexico) have made it happen. As of now, none of these programs distribute naloxone to inmates while they are incarcerated, or as they are leaving custody, but they do provide vital overdose education and referral to local naloxone programs on the outside.
To gain entrée to the correctional system, it is important to find an ally, someone who is on the inside who you can present the idea to, and who has the power to help move it through the proper channels to gain approval from the facility. Some jails and prisons have public health interventions in place already, like HIV testing or peer-led HIV prevention, or they have a jail health program that could be a good place to start. You can also check to see if the correctional system has an offender re-entry program, or case management program — these are also possible places to find an ally who understands the increased risk of overdose for people leaving prison and re-entering the community. If your local department of public health already works within the prisons, contact them to inquire about proposing an overdose prevention group. Many jails and prisons also have drug treatment components that may be interested in incorporating overdose prevention into their existing workshops and group activities.
Providing Overdose Prevention Training in a Corrections Setting
Policies in corrections settings must be respected or you won’t be allowed in to do the important work you want to do. So: Follow their rules. Vent later. Your goal is to get information to the individuals who are locked up, and dealing with correctional officers and prison administrators is the only way you’ll get to do that. Plus, you never know where you will find an unlikely ally, so don’t assume the worst from the start.
Similar to the suggestion above, follow the proper channels to get approval to enter the corrections system and keep all relevant parties informed of your intentions, content and actions. Similar to providing overdose prevention in drug treatment settings, if participants (or correctional officers, wardens, etc.) express discomfort about discussing drug use or relapse, it’s important to try framing the training as “how to save a life” and to discuss the possibility of witnessing overdose among other people, like family or friends, who may continue to use and who may be at risk.
Parent and Family Groups
All across the country, parents and loved ones of people who use drugs have been organizing in a variety of ways to support each other, advocate for drug policy reform, and expand access to drug treatment. Further, some of these parent groups have embraced overdose prevention and naloxone as a strategy to help keep their loved ones alive. Overdose prevention and harm reduction strategies can be a tough sell at first for some parents and loved ones, who may feel that these strategies are either enabling, or take the focus off getting their loved one into treatment. When responding to these concerns, focus on the life-saving and empowering nature of being prepared to save someone from an overdose; overdose prevention is not meant to be a “solution” to their loved one’s drug use but rather, a way to keep them alive another day.
Be mindful that parents and loved ones who are organized as part of a 12-step program may not be able to invite an outside group to provide overdose education, because this violates some of the traditions of 12-step programs. However, if a member of one of these fellowships wishes to host separate overdose prevention trainings, they can do so. Groups that are not 12-step affiliated have more flexibility to offer educational workshops and to invite guests to their meetings.
Tips for Providing Overdose Prevention Training with Loved Ones, Including Parents, Family and Friends
- Referrals to support groups and grief counseling.
- Support to address anger that these resources (overdose prevention information and naloxone) were not previously made available.
- Disclosure at the beginning of the group that it will explicitly address overdose, and that it could be emotionally charged and painful.
- Be mindful that discussions about involuntary drug treatment and increased overdose risk are important but also may become heated and lengthy, so plan time accordingly.
- Some loved ones may want to get involved in advocacy or activism — be prepared with suggestions for these opportunities (advocacy opportunities for pending legislation, local coalitions, etc.).
- Discuss ways that family and friends can communicate to their loved one(s) who use(s) drugs that they have naloxone and are trained to use it, without making that person feel as if they will be punished with the naloxone.
- All groups should be reminded that using naloxone as punishment (i.e. — administering naloxone to someone who is not experiencing overdose or administering too much naloxone) will be counterproductive.
Considerations for Engaging Medical Professionals
- Share information about other overdose prevention initiatives carried out by physicians and medical providers and offer reassurance about the legality of naloxone prescription. Gather information and support documents from other programs doing similar work, such as Project Lazarus. Bring documentation on legality of prescribing naloxone (i.e. Scott Burris’ article on naloxone prescription).
- Be prepared to provide suggestions about different ways that patients can be educated about overdose. Providers may be resistant to having to squeeze one more thing into their visits with patients. There are creative ways that programs have addressed this, including the use of pamphlets, videos (including the Project Lazarus patient education video: http://projectlazarus.org/patients-families/videos), or referrals to health workers, interns or counselors on staff that could provide the overdose education.
- Be prepared to discuss barriers to enacting a traditional prescription model and offer examples of how this has been carried out successfully in other places around the US (North Carolina, Pittsburgh, Massachusetts).
- Clinics and doctors may have questions about how to bill for overdose prevention services and how naloxone can be covered by insurance. Several programs report that they bill for naloxone under opioid abuse/use codes for Medicaid.
- If providers want to differentiate opioid “misusers” from the rest of their opioid using patients, refer to the inclusion criteria for naloxone prescription and reframe the issue as “opioid safety education” or “patient safety.” Anyone taking opioids can benefit from overdose prevention education.
Access to Naloxone
Access to naloxone has increased significantly in recent years. Many pharmacies distribute naloxone to community members, though it is kept behind the counter. If you’re looking for naloxone, state and local health departments are a great place to start.
Naloxone Priority Groups and Risk Factors for Opioid Overdose
- Recent medical care for opioid poisoning/intoxication/overdose
- Suspected or confirmed history of heroin or nonmedical opioid use
- High-dose opioid prescription (≥100mg/day morphine equivalence)
- Any methadone prescription for opioid naive patient
- Recent release from jail or prison
- Recent release from mandatory abstinence program or drug detox program
- Enrolled in methadone or buprenorphine detox/maintenance (for substance use or pain)
- Any opioid prescription and known or suspected:
- Smoking, COPD, emphysema, asthma, sleep apnea, or other respiratory system disease
- Renal or hepatic disease
- Alcohol use
- Concurrent benzodiazepine use
- Concurrent antidepressant prescription
- Remoteness from or difficulty accessing medical care
- Voluntary patient request