Module 4: Program Implementation and Management
Existing programs have found creative ways of funding overdose prevention efforts for many years.
In some cases, state, county or city public health departments have found ways to designate money towards overdose prevention activities. As mentioned in The DOPE Project case study, the City and County of San Francisco’s Public Health Department allocated seed money to the DOPE Project out of their general fund. The Massachusetts Department of Public Health, New Mexico Department of Public Health, and New York State Department of Health all supply naloxone for the programs in their states, but do not pay for additional staff at those programs. These states operate under a model wherein individual programs are expected to integrate naloxone distribution into their existing array of services and therefore do not need additional staff or infrastructure. The state only provides support and naloxone.
Other programs have sought out private donations or foundation grants to purchase naloxone. Still other programs have received support and funding from Medicaid, or used money from existing contracts (like an HIV prevention contract, for example), to support overdose education and take-home naloxone programs. A strong case can be made that overdose prevention should be part of all HIV-related programming. If you need references to make this argument, check out the great document from the Eurasian Harm Reduction Network and the Open Society Foundations, Why Overdose Matters for HIV. Also noteworthy, in the early days of take-home naloxone programs, some universities and research groups received funding to conduct studies that included distribution of naloxone and overdose prevention education, and they were paid for out of those grants.
The most important thing to remember is that take-home naloxone programs do not cost a lot of money, especially when you are first starting and don’t require a large volume of naloxone. If you are folding take-home naloxone and overdose prevention into an existing program, you will not need to hire and train new staff. You will, however, need money for supplies and possibly training for current staff. It is better to start with whatever money you can find than to wait for the day when a funding stream appears.
Pharmaceutical companies state that the shelf life of naloxone is approximately two years. However, some studies have shown that it can last up to 30 years. Naloxone should be kept out of direct light, and at room temperature (between 59 and 86 degrees Fahrenheit). It is important to order an accurate amount of naloxone so that you don’t run out or have too much (otherwise it might sit around unused and then expire). At first, it might be difficult to estimate supply needs, but if you keep a record of demand over time, you will be able to adjust your orders accordingly.
There are different ways you can assemble your naloxone kits. You will need some kind of container, like a bag or a small sharps container, such as a Fitpak.
Developing Written and Visual Materials
You may want to provide participants with written materials about overdose prevention and using naloxone. Whenever possible, these should be tailored to your community, and produced in the languages that are most common among your participants. Written materials will ideally include easy-to-understand visuals and summarize the training so they can be referenced later.
Written materials should include, but are not limited to, the following:
- Overdose prevention strategies
- Explanation of overdose risks
- How to recognize an overdose
- Overdose response, including: stimulation, calling 911, rescue breathing and naloxone administration
- Aftercare information
- Contact information for getting naloxone refills
Overdose prevention programs have created many great brochures and educational pamphlets. Please feel free to draw inspiration from them to create your own, or adapt existing materials for your program.
Data Collection and Paperwork
Data collection requirements are going to be different depending on who is funding your program, and in some cases, who is overseeing it. For example, if your State Public Health Department is supporting your program, they may ask you to collect data during your overdose trainings. Some programs do not collect any data; some collect so much that it becomes a barrier. Completing paperwork and data collection should never be a barrier to someone receiving naloxone.
Some take-home naloxone programs create a registration or enrollment form to document that they have trained someone and prescribed them naloxone; some programs use codes or unique identifiers to document who has received naloxone. It is important to keep a record of who has been given a naloxone prescription so that they can get a refill from your program without going through another training. Registration or enrollment forms can also serve as a medical record, establishing that there was contact between the person receiving the naloxone prescription and a medical provider. Some programs will conduct a brief overdose history or risk assessment with the person being trained, along with collecting basic demographics.
You can put stickers on the naloxone or distribute prescription cards that state that the naloxone belongs to the participant, was obtained from an overdose prevention program and was prescribed by a medical doctor. Some programs put the name of the trained participant on the stickers and cards, along with the name and license number of the physician. While it is extremely rare that someone gets charged with possession of naloxone, having a valid prescription with their name and a doctor’s name can minimize the chance of police harassment or arrest.
It is recommended that participants be able to get unlimited refills, for any reason. It is important to meet the needs of your participants who may have difficulty keeping their naloxone kit with them due to frequent moves, staying outside, theft of their belongings, or confiscations by police or public works. You may have some participants who request refills often, but many others will not need multiple refills, so it does balance out. It is not recommended that you require a participant to bring back their old naloxone kit, or put a limit on how many refills they can receive in a given period of time.
A separate contact form can be used for refills, to document whether the person used their naloxone, lost it, had it confiscated or if it was destroyed. The most important information you can collect is that a participant used his or her naloxone to save a life; it documents that someone who was trained and given naloxone by your program reversed an overdose. Confiscation data is helpful to collect so that you can follow up on repeated incidents of law enforcement or others confiscating naloxone. Each program should tailor all forms to meet the specific needs of the program, any funders and the prescriber.
Assembling Naloxone Kits
- If you are distributing vials of naloxone, include several muscle syringes so that participants have one syringe per 1ml injection. 3ml, 25g, 1-inch syringes are recommended, but different gauges and point lengths are sometimes used, like 3ml, 22g, 1 ½ inch. Any option is okay as long as the point is at least 1 inch long so that it can reach the muscle.
- If you are distributing 1ml vials of naloxone, include at least two vials in the kit, with 2 muscle syringes.
- If you are distributing 2ml vials and needleless luer-lock syringes for intranasal administration, include two boxes of naloxone/syringe and use a rubber band to attach an atomizer (Mucosal Atomization Device) to each box.
- Optional items for the kits include: alcohol pads, rescue breathing masks, rubber gloves, prescription cards, and educational inserts.
- You can put your kits in plastic baggies or purchase other containers such as bags with zippers.
Policy and Procedure Manuals
It is a great idea to document how your take-home naloxone program works. Some programs and funders require policy and procedure manuals, so you may have no choice; regardless, it is a good idea to document your work so that it can be sustained over time, despite staff changes.
Developing a Policy and Procedure Manual
A policy and procedure manual can include the following items:
- Background about the effectiveness of overdose prevention
- Community planning data (research and local overdose data)
- Roles and responsibilities (for example, prescribing physician, medical director, program director, outreach counselors, etc.)
- Program logistics (ordering and storing naloxone and other supplies, assembling kits)
- Sites where naloxone prescription/overdose trainings occur
- Sample curricula for short format and longer format trainings and workshops
- Staff training requirements
- Emergency contacts and onsite overdose protocol
- Educational materials
Overdose training and naloxone distribution can be done on the street, in parking lots, behind cars, in alleys, at syringe access programs, in people’s living rooms, in doctor’s offices, in hotel rooms, housing programs, at parent support groups, in jails, detoxes, methadone clinics, at universities and just about anywhere people ask for it. You can do either short format trainings (good for needle exchange or outreach) or groups and workshops when you have more time.
Tips for Providing Overdose Prevention and Naloxone Trainings
Here are some general tips for doing overdose prevention and naloxone trainings:
- People may only have a short amount of time. Tailor your training to meet the needs of the audience. If they have 10 minutes, make it 10 minutes. If they have 3 minutes, make it 3.
- Respect personal experience. Individuals may have reversed overdose in the past and could be offended if they perceive criticism of their methods. Anything that was tried in the past to revive someone was done in the interest of keeping that person alive, so it was never wrong; it was what the person knew to do in the moment.
- Honor the history of the involvement of people who use drugs in overdose prevention. Although public health programs are now working to reduce overdose, people who use drugs have been aware of, and trying to curb overdose, for many years. It is vital to acknowledge and honor their contributions, and the loss of so many loved ones.
Some programs or individuals who start providing overdose prevention and take-home naloxone are already connected with people who may be at risk for overdose, or their friends, family or loved ones. Others will have to start from scratch finding folks who may need naloxone or information about overdose. Reaching Out to At-Risk Populations offers some suggestions that we’ve gathered from other overdose prevention and take-home naloxone programs for making contact with people who need these services the most. These are just suggestions, and as always, it is important to develop outreach strategies that make the most sense in your community.
Reaching Out to At-Risk Populations
- Partner with agencies that are already working with higher risk groups, such as people recently released from incarceration, hospitals, or drug treatment facilities.
- If direct collaboration with a drug treatment program, shelter, or medical facility is not possible, find a public place, such as a park or restaurant nearby where you can do education and/or naloxone trainings.
- Ask managers of restaurants, cafes and retail stores in areas impacted by drug use whether overdose has occurred in bathrooms; offer to review safety plans with staff or provide overdose response training. You could also ask to leave outreach materials in their bathrooms.
- To reach encampments of people experiencing homelessness, try to find an ambassador who can assist with initiating outreach in a way that promotes trust. Outreach workers working within encampments should behave similarly to being invited into someone’s home, even if the space is technically public space.
- Ask participants who are frequent refillers to connect likely bystanders and frequent overdosers with the agency. Consider offering to schedule home visits for groups assembled by frequent refillers.
- Set up a Google Alert for articles, news stories or blog posts related to overdose and post a comment encouraging readers to access overdose prevention and response services.
- Form relationships with local pharmacies that fill prescriptions for opioids and/or sell syringes and ask if you can leave outreach materials with them for their customers.
Reaching Out to Police and First Responders
It is important to inform your local law enforcement agency and first responders (EMS, Fire) that you will be providing naloxone and training participants to respond to overdose. One way to do this is to send a letter to the agencies introducing your program and explaining what will be happening, including photos of your naloxone kits.
You can also request a meeting with responders, and a chance to speak to officers at roll call meetings to explain the program. If you are able to arrange a visit to Fire, EMS or Police to discuss your naloxone program, be prepared for a wide range of reactions from supportive to hostile.
Some programs are supported by state health departments, which provide them with some leverage when communicating with law enforcement. For example, in New York State, the NYS Division of Criminal Justice Services Office of Public Safety in consultation with the NYS Department of Health AIDS Institute, issued a Program Advisory to all NYS Law Enforcement agencies about syringe exchange and opioid overdose programs, along with a podcast that was made available online for law enforcement officers called Syringe Law and Harm Reduction Programs.
Tips When Working with First Responders
- Be prepared to discuss and field questions about perceived ethical dilemmas of providing naloxone to people who use drugs. Common questions include: Will it support continued or more use? Why help people who are doing illegal activities? Why should we spend taxpayer money on people who use drugs when there are people with “real” emergencies?
- Offer information and background on the legal basis for the project.
- Be prepared to discuss drug use trends, basic harm reduction and drug-related stigma. While first responders often have a lot of contact with people who use drugs, many also lack information about drug use because they are rarely in a position to form trusting relationships with people who use drugs.
- Some first responders are not able to carry or administer naloxone because of internal policies and regulations. They may be resentful that they are not allowed to administer naloxone, while laypersons can. Suggest that they advocate changing these policies; offer examples of places where such efforts have been successful.
- Discuss scenarios in which First Responders arrive after a participant has already used naloxone to revive someone. How will they react?
- Emphasize the importance of not confiscating naloxone kits and reinforce any legal basis for not confiscating if applicable.
- Empower First Responders as allies, highlighting your shared goals and responsibilities to promoting safety and public health.