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Service Delivery Innovation Profile

State Health Department and Community Agencies Save Lives by Teaching Potential Bystanders To Recognize and Respond to Opioid-Related Overdoses


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Snapshot

Summary

Under the direction of the Massachusetts Department of Public Health, public health and community-based agencies throughout Massachusetts use trained, nonmedical workers to teach potential bystanders how to prevent, recognize, and respond to an opioid-related overdose, including administering nasal naloxone (a drug that can reverse the effects of the overdose). Known as Overdose Education and Naloxone Distribution, the program primarily targets high-risk communities that in recent years experienced a large number of overdoses. Since the inception of the program, Overdose Education and Naloxone Distribution has trained more than 18,700 individuals throughout Massachusetts. Opioid-related deaths occur at lower rates in communities that have implemented the program than in those that have not, even when implementation has not been widespread. The program has not had an impact on opioid-related emergency department visits and inpatient admissions.

Evidence Rating (What is this?)

Moderate: The evidence consists primarily of comparisons of opioid-related death rates, hospitalizations, and ED visits in communities that implemented the program to those that did not. Additional evidence includes post-implementation trends in the number of potential bystanders trained by the program.
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Developing Organizations

Massachusetts Department of Public Health
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Use By Other Organizations

OEND programs have been implemented in some other communities around the United States. Between 1996 and 2010, these programs collectively educated more than 50,000 potential bystanders, resulting in more than 10,000 overdose rescues with naloxone.1 The program is likely to spread further in the future, because in March 2012 the United Nations Commission on Narcotic Drugs recognized overdose as a global public health issue that warrants focus by the World Health Organization and its member countries, and recommended further work to promote use of naloxone.2

Date First Implemented

2006
The program began in September 2006.begin pp

Patient Population

Vulnerable Populations > Substance abusersend pp

Problem Addressed

Drug overdoses are a common, growing problem, and have become the leading cause of death by injury in the United States. Overdose-related deaths can often be prevented by calling emergency medical services (EMS), performing rescue breathing, and administering naloxone (a drug that reverses the effects of the overdose) in a timely manner, but often no one around the individual experiencing an overdose recognizes the signs or knows how to respond.
  • An increasingly common and deadly problem: Poisonings (roughly 90 percent of which relate to drug overdoses) are the leading cause of death by injury in the United States.3,4 Overdose-related fatalities, inpatient admissions, and emergency department (ED) visits have increased in the United States over the last several decades, driven primarily by the growth in prescriptions for opioids to manage pain and use of these drugs for nonmedical reasons.5,6,7,8 In Massachusetts, opioid-related overdose deaths have exceeded motor vehicle deaths since 2005.9
  • Unrealized potential of early recognition and quick response: Overdose-related deaths can often be prevented by calling EMS, performing rescue breathing, and administering naloxone in a timely manner. However, before implementation of this program in Massachusetts, few potential bystanders (e.g., family members and friends of opioid users, social service agency staff) knew how to recognize the signs of an overdose or how to respond when one occurred.

What They Did

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Description of the Innovative Activity

Under the direction of the Massachusetts Department of Public Health, public health and community-based agencies throughout Massachusetts use trained, nonmedical workers to teach thousands of potential bystanders how to prevent, recognize, and respond to an opioid-related overdose, including administering nasal naloxone. Known as Overdose Education and Naloxone Distribution (OEND), the program primarily targets high-risk communities that in recent years experienced a large number of overdoses. Key program elements are outlined below:
  • Participating communities and agencies: At present, 15 public health and community-based agencies participate in the program, with some agencies having sites in multiple locations and communities. Participating agencies include needle exchange programs, HIV education drop-in centers, other HIV prevention and screening programs, EDs, a substance abuse treatment staff training program, and support groups for parents with opiate-addicted children. These agencies distribute kits and train first responders (police and fire) and staff at detoxification centers, HIV education drop-in centers, addiction treatment programs, recovery houses, and other organizations that routinely serve those at risk of an opioid-related overdose or their friends and family. The program focuses on communities where opioid-related overdoses are a significant problem. For example, during the first 3 years of the program (2006 to 2009), implementation was tested in 19 communities that had experienced 5 or more opioid-related overdoses in the previous 3 years. These communities were home to approximately 30 percent of the state’s population, but accounted for roughly half its fatal opioid overdoses and hospital admissions for nonfatal overdoses.
  • Training the trainers: Each participating agency has at least one designated staff person who knows how to teach potential bystanders to recognize and respond to an overdose, including administering nasal naloxone. To perform this work, these individuals must complete a 4-hour didactic training and multiple supervised training sessions with potential bystanders under the supervision of someone who has already completed the course. When the program was launched, a public health nurse who was instrumental in creating the training curriculum played this “master trainer” role. (The Planning and Development Process section provides more information on the curriculum.) Typically, it takes several months after an agency joins the program before the designated staff person completes this training and can begin working with fellow staff and other potential bystanders.
  • Group and individual education and training: At each participating agency, the designated person teaches other staff and clients (particularly opioid users and their friends and family members) how to prevent, recognize, and respond to an overdose. The format and length of the sessions vary across agencies, with some holding one-on-one sessions that take as little as 10 minutes and others holding group sessions that might last for an hour. For example, a local support group for parents of children with opiate addiction integrates the education and training into each of its seven weekly group meetings throughout Eastern Massachusetts. By contrast, a local health center provides one-on-one training to at-risk individuals who come to the center for health services, including needle exchange. Regardless of the format used, the basic components remain the same, consisting of the following elements:
    • Education: This component emphasizes key strategies for preventing overdoses, including reducing polysubstance misuse (e.g., simultaneous use of opioids and alcohol, benzodiazepine, or cocaine); not using drugs alone; and accounting for reduced tolerance after a period of abstinence. It also focuses on how to recognize a potential overdose by assessing for unresponsiveness and decreased respirations, and how to respond by seeking help (e.g., calling EMS), providing rescue breathing, administering nasal naloxone, and staying with the person until medical personnel arrive or the person recovers.
    • Administering naloxone: During the session, attendees must demonstrate that they know how to assemble the naloxone device and administer the drug properly.
    • Distribution of rescue kits: Each individual who successfully completes the training receives a naloxone rescue kit that has instructions on how to administer the drug, two doses in prefilled syringes (in case one dose is not sufficient or overdose symptoms return), and two atomization devices for administering the drug.
  • Periodic cross-agency networking: The agencies participate in quarterly "all-site" meetings that give representatives of participating agencies an opportunity to discuss any challenges and issues they may be facing. These sessions give the steering committee at the department of public health a chance to lay out key priorities for the program, such as a recent desire to reach more parents of opiate users. In addition, the medical director hosts an “adverse-event” call each month in which agencies discuss individual cases and other challenges in implementing and operating the program. These meetings and calls help to ensure cross-agency consistency in how the education and training are administered.

Context of the Innovation

Headquartered in Boston, the Massachusetts Department of Public Health is a governmental agency with various responsibilities related to public health within Massachusetts. The Department supports all Massachusetts residents, with a particular focus on the underserved. The Department seeks to promote healthy people, families, communities, and environments through the compassionate provision of care, education, and preventive services.

The impetus for this program began in the mid-2000s in the cities of Boston and Cambridge, as public health officials and emergency medical technicians (EMTs) began to see an increase in the number of opioid-related overdoses in the community. In addition, several overdoses that occurred in public received ample media attention in the area.

Did It Work?

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Results

Since it began in 2006, the program has trained more than 17,000 individuals throughout Massachusetts to recognize and respond to an opioid-related overdose. Opioid-related deaths occur at lower rates in communities that have implemented the program, even when implementation has not been widespread. The program has not had an impact on opioid-related ED visits and inpatient admissions.
  • Many potential bystanders trained: During the program’s first 3 years of operation (2006 to 2009), it reached nearly 3,000 individuals in 19 communities.10 Over the next several years, it successfully trained many more potential bystanders to an overdose, with more than 17,000 having been trained by early 2013. Each month the program educates and trains roughly 300 to 450 additional individuals.
  • Significantly fewer deaths: The program has significantly reduced opioid-related deaths, as outlined below:
    • Many rescues: During the program’s first 3 years, those who completed the training attempted 327 rescues, succeeding in 98 percent of these attempts.10 At present, the program receives reports of roughly 30 rescues each month, equivalent to 1 a day.
    • Lower death rates: Opioid-related death rates were significantly lower in communities that implemented the program than in those that did not. For example, compared to areas without the program, death rates were 46 percent lower in communities where the program achieved a high degree of penetration (defined as more than 100 out of every 100,000 residents having been educated and trained), and 27 percent lower in communities that achieved a low degree of penetration (between 1 and 100 out of every 100,000 residents trained). Although these results suggest a “dose effect” from the program (i.e., that greater penetration led to fewer deaths), the difference in death rates between communities with high and low degrees of penetration did not meet the test of statistical significance, due in part to the small sample size involved. (For the purpose of this analysis, nonimplementing communities included all 19 communities in the 3-year period before the program began, along with 12 communities where no one enrolled in the program in 2006 and 5 communities where no one enrolled in 2007.)10
  • No impact on hospital use: During its first 3 years, the program did not have a statistically significant impact on opioid overdose-related ED visits or inpatient admissions.10 Program leaders are not surprised by this finding, which likely stems from two countervailing forces—on the one hand, the program teaches people to call 911 immediately when they suspect an overdose, which likely leads to more ED visits and inpatient admissions. At the same time, the program helps people recognize and respond to potential overdoses in a timely manner, which likely averts some ED visits and admissions.

Evidence Rating (What is this?)

Moderate: The evidence consists primarily of comparisons of opioid-related death rates, hospitalizations, and ED visits in communities that implemented the program to those that did not. Additional evidence includes post-implementation trends in the number of potential bystanders trained by the program.

How They Did It

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Planning and Development Process

The program began as a pilot test and has expanded and evolved to its present state over time; key steps included the following:
  • Initial launch in Boston with EMTs: In 2005, in response to increased overdoses in the city, Boston Emergency Medical Services (Boston EMS) applied for a special waiver to permit EMTs to carry and administer nasal naloxone in cases of suspected overdose. Although not approved by the Food and Drug Administration for this route of administration, nasal naloxone became the local standard of care in the area for prehospital treatment of opioid overdose, because it could be administered without a needle injection into a muscle or vein, reducing the chance of a needle stick injury.
  • Expansion to syringe access programs in Boston and Cambridge: In 2006, public health departments in Boston and Cambridge began training syringe access clients in overdose prevention and equipped them with naloxone rescue kits. To prepare for this expansion, a public health nurse from Boston visited New York City and Baltimore to learn about their bystander naloxone programs. The nurse reviewed the training materials being used in these cities, in addition to a curriculum developed by the Harm Reduction Coalition and the Chicago Recovery Alliance. She adapted these materials to the approach being used in Massachusetts. The medical director of Boston EMS wrote the standing order, with approval from the public health board, that allowed for nonmedical public health staff to train clients and distribute naloxone rescue kits. In Cambridge, city public health nurses provided overdose education and trained clients at the syringe access program to administer naloxone.
  • Training curriculum to facilitate statewide expansion: Based on the experiences in Cambridge and Boston, leaders of the Massachusetts Department of Public Health decided in 2007 to expand the program significantly, to other needle exchange programs and to HIV prevention programs. They adopted the standing order model as a public health pilot program in which the medical director of the program wrote a standing order permitting trained agency workers to provide overdose education and equip community members with naloxone rescue kits.
  • Expansion over time: In 2007, four additional community-based agencies joined the program, and in 2009 two more organizations began participating. Over the next 4 years, 7 additional community-based programs have joined the effort, including several local police and fire departments and an organization that sponsors support groups for parents with opioid-dependent children.

Resources Used and Skills Needed

  • Staffing: The program has a part-time medical director who spends roughly 4 hours a week on program-related activities. Existing staff within participating agencies work on the program as part of their regular job responsibilities.
  • Costs: Annual program costs total roughly $300,000, which covers data management, the naloxone kits, and the medical director’s time. This figure does not include the staff who implement the program in the community, as it is integrated into existing community-based programs.
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Funding Sources

Centers for Disease Control and Prevention; Massachusetts Department of Public Health; Substance Abuse and Mental Health Services Administration (U.S.)
The Massachusetts Department of Public Health funds the program through its Bureau of Substance Abuse Services and Bureau of Infectious Disease (which includes the Office of HIV/AIDS). The Centers for Disease Control and Prevention, the Substance Abuse and Mental Health Services Administration, and appropriations from the state of Massachusetts also provide funds to the two bureaus that support program operations.end fs

Tools and Other Resources

The Harm Reduction Coalition has created a manual that outlines the development and management of an Overdose Prevention and Education Program, both with and without a take-home naloxone component. This manual is available at: http://harmreduction.org/issues/overdose-prevention/tools-best-practices/manuals-best-practice/od-manual
/
.

An article exploring the cost-effectiveness of distributing naloxone to heroin users for the reversal of overdoses is available at: http://annals.org/article.aspx?articleid=1487798.

A guide describing the knowledge and core competencies necessary for potential overdose responders trained as part of the Massachusetts Department of Public Health opioid overdose prevention pilot program is available at: http://www.mass.gov/eohhs/docs/dph/substance-abuse
/core-competencies-for-naloxone-pilot-participants.pdf
(If you don't have the software to open this PDF, download free Adobe Acrobat ReaderĀ® software External Web Site Policy.).

Adoption Considerations

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Getting Started with This Innovation

  • Consult existing resources: As noted, the Harm Reduction Coalition has developed a guide to help in creating this type of program; a link is provided in the Tools and Other Resources section.
  • Enlist leadership support to advocate for regulatory approval: Some sort of regulatory guidance or ruling is generally required to allow for the distribution and administration of nasal naloxone by nonmedical personnel. In Boston, the public health commissioner’s support for this approach proved critical to securing approval from the local public health board to allow distribution of naloxone by nonmedical personnel under the medical director’s standing order. This same individual then served as the commissioner at the State level, and his support was key in allowing the Massachusetts Department of Public Health to run the program under its authority to conduct pilot programs that inform regulations. To date, no formal body at the State level has formally approved distribution of nasal naloxone by nonmedical personnel.
  • Consider use of trained nonmedical personnel: Nonmedical personnel have access to the target population and have the time and flexibility to deliver the service in a variety of settings. They interface with the target population in drop-in centers, needle exchanges, detoxification programs, and other addiction treatment programs, and through targeted and "street" outreach. Medical providers cannot offer services in this wide a variety of settings, and requiring an interaction with a medical provider for the distribution of naloxone creates barriers to access for the target population and increases costs. If nonmedical personnel are used, these individuals need to be trained.
  • Leverage existing community-based agencies: Many communities have existing agencies that serve those at risk of an overdose, and agency staff are often eager to have additional tools at their disposal to help those with drug addictions.
  • Minimize barriers: Program leaders should make it as easy as possible for trained individuals to distribute and administer nasal naloxone, such as by creating a standing order that allows any qualified individual to do so.

Sustaining This Innovation

  • Push for formal regulations or legislation: The program’s ability to continue functioning will be enhanced by the issuance of formal regulations or legislation to explicitly permit nonmedical personnel to distribute under a standing order. In Massachusetts, legislation (a “Good Samaritan” law and a law that limits legal liability) provides safeguards to anyone who administers naloxone in good faith at the scene of a presumed overdose and limits the liability of prescribers.
  • Consider partnership with public safety: Realizing the important role that first responders play in recognizing and reacting to overdoses, program leaders recently began partnering with a few local police and fire departments. This partnership has started to change the culture between public health and public safety, two groups that historically have not collaborated closely in Massachusetts.
  • Reach out to parent groups: Parent support groups have proven very receptive to this program, and hence have become an excellent vehicle to reach individuals who are likely to witness an overdose of a loved one. In addition, the leaders of these parent groups have become vocal, sympathetic advocates for the program with legislators and the public at large, with some parents being featured in local media.

Use By Other Organizations

OEND programs have been implemented in some other communities around the United States. Between 1996 and 2010, these programs collectively educated more than 50,000 potential bystanders, resulting in more than 10,000 overdose rescues with naloxone.1 The program is likely to spread further in the future, because in March 2012 the United Nations Commission on Narcotic Drugs recognized overdose as a global public health issue that warrants focus by the World Health Organization and its member countries, and recommended further work to promote use of naloxone.2

More Information

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Contact the Innovator

Sarah Ruiz
Assistant Director of Planning and Development
Massachusetts Department of Public Health
250 Washington Street, 3rd floor
Boston, MA 02108
E-mail: sarah.ruiz@state.ma.us

Alexander Y. Walley
, MD
Assistant Professor of Medicine
Co-Program Director, Addiction Medicine Fellowship Program
Program Director, Fellow Immersion Training Program
Clinical Addiction Research and Education Unit
Section of General Internal Medicine
Boston University School of Medicine
Boston Medical Center
801 Massachusetts Avenue, 2nd Floor
Boston, MA 02118
E-mail: awalley@bu.edu

Innovator Disclosures

Ms. Ruiz reported having no financial interests or business/professional affiliations relevant to the work described in this profile. In addition to the funders listed in the Funding Sources section, Dr. Walley reported receiving consulting fees from Social Sciences Research Incorporated for reviewing materials for an online first responder overdose training module.

References/Related Articles

Walley AY, Xuan Z, Hackman HH, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ. 2013;346:f174. [PubMed]

Footnotes

1 Centers for Disease Control and Prevention (CDC). Community-based opioid overdose prevention programs providing naloxone—United States, 2010. MMWR Morb Mortal Wkly Rep. 2012;61:101-5. [PubMed]
2 United Nations Commission on Narcotic Drugs. Resolution 55/7. Promoting measures to prevent drug overdose, in particular opioid overdose. 2012 Mar. Available at: http://www.unodc.org/documents/commissions/CND/Drug_Resolutions/2010-2019/2012/CND_Res-55-7.pdf
3 Warner M, Chen LH, Makuc DM, et al. Drug poisoning deaths in the United States, 1980-2008. NCHS Data Brief. 2011;81:1-8. [PubMed]
4 Centers for Disease Control and Prevention, National Center for Injury Prevention and Control. Web-based Injury Statistics Query and Reporting System (WISQARS) 2005. 2012 Sept. Available at: http://www.cdc.gov/injury/wisqars/index.html.
5 Centers for Disease Control and Prevention (CDC). Vital signs: overdoses of prescription opioid pain relievers—United States, 1999-2008. MMWR Morb Mortal Wkly Rep. 2011;60:1487-92. [PubMed]
6 Hall AJ, Logan JE, Toblin RL, et al. Patterns of abuse among unintentional pharmaceutical overdose fatalities. JAMA. 2008;300:2613-20. [PubMed]
7 Paulozzi LJ, Ryan GW. Opioid analgesics and rates of fatal drug poisoning in the United States. Am J Prev Med. 2006;31:506-11. [PubMed]
8 Coben JH, Davis SM, Furbee PM, et al. Hospitalizations for poisoning by prescription opioids, sedatives, and tranquilizers. Am J Prev Med. 2010;38:517-24. [PubMed]
9 Massachusetts Department of Public Health, Division of Research and Epidemiology, Bureau of Health Information, Statistics, Research, and Evaluation. Massachusetts Deaths 2008. 2010;63-71. Available at: http://www.mass.gov/eohhs/docs/dph/research-epi/death-report-08.pdf.
10 Walley AY, Xuan Z, Hackman HH, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ. 2013;346:f174. [PubMed]
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Original publication: March 12, 2014.
Original publication indicates the date the profile was first posted to the Innovations Exchange.

Last updated: May 07, 2014.
Last updated indicates the date the most recent changes to the profile were posted to the Innovations Exchange.