From Underground to State-Funded: The History of Overdose Prevention/Naloxone Distribution in Massachusetts First state funded programs began toward the end of 2007 in Boston, Cambridge, New Bedford/Fall River, Quincy, Lynn/Gloucester, Brockton, Provincetown/Hyannis, and Springfield/Northampton. In 2010 the State expanded into four additional communities; Lowell, Lawrence, Holyoke, and Worcester. The selected communities reflect cities with the highest rate of fatal and non-fatal overdose. Adam Butler, Jon Zibell, Kathy Day, Monique Tula and Gary Langis

Purpose To describe in timeline format the history of Overdose Prevention in Massachusetts To describe how OD Prevention went from an underground effort to a comprehensive, state- sanctioned & funded program that includes naloxone distribution To describe the various initiatives that have been developed and integrated into other services over time. To share successes, challenges, key opportunities and identify ways for different types of organizations (underground, CBO, state) to all play a part in developing a successful program and initiatives .

National and Regional Drug Threat United States New England 38.8% 37.6% 36.5% 33.2% 15.5% 11% 8.5% 9.3% 3.9% 1.9% Strategic Findings • The availability of Mexican heroin is increasing, albeit slightly, in eastern heroin markets traditionally supplied by South American heroin. • Mexican DTOs increasingly are transporting and distributing South American heroin in eastern U.S. drug markets, on behalf of Colombian DTOs. • Continued declines in heroin production in South America could result in increased availability of Mexican and Asian heroin in eastern U.S. heroin markets. Heroin Cocaine Methamphetamine Marijuana Pharmaceuticals Heroin Cocaine Methamphetamine Marijuana Pharmaceuticals Source: National Drug Threat Assessment, 2007

Opioid-related Health Problems 2007, rates per 100,000 by Town Identifying areas of high opiate use and potential of overdose. The darker blues are also where the state has sited Naloxone programs Rates suppressed for towns with less than 5 cases Source: Massachusetts Registry of Vital Records and Statistics (MA-RVRS)

Opioid-Related Poisoning Deaths 1990-2008 Explaining the rise in incidents of fatal overdose over the past decade and contributing factors i.e. availability of prescription drugs. Source: Massachusetts Registry of Vital Records and Statistics (MA-RVRS)

Active players: Underground Community-Based Organization 2000 Active players: Underground Community-Based Organization Discussing how the underground distribution of Naloxone began in MA and how community based organizations would get the word out to their participants that it was happening.

Community-Based Organization 2001 Active players: Underground Community-Based Organization Cambridge Cares receives funding for overdose prevention, underground distribution continues on the North Shore, Springfield, Boston, and Cambridge.

Community-Based Organization 2002 Active players: Underground Community-Based Organization CCAA begins to work more formerly with underground distributors providing space where their participants could be trained by NEPA staff and a peer educator, underground continues in other areas.

Community-Based Organization 2003 Active players: Underground Community-Based Organization CCAA and other programs attempt to have Naloxone distribution introduced as legislation with little luck of finding a legislative sponsor

Community-Based Organization 2004 Active players: Underground Community-Based Organization CCAA asks for Board of Director support for Naloxone distribution. Distribution remains underground. NEPA (underground) is collecting limited data, demographics, and information on reversals. First overdose vigil held in Cambridge.

2005 Active players: Underground Community City Naloxone distribution is discontinued at CCAA after meeting between Board members and NEPA personnel due to legalities and liability concerns but Board members recognize and support further discussion with BPHC officials. CAB holds its first overdose vigil, 200 persons attend, CAB creates NOMAD (NOT One More Anonymous Death) website. Fatal overdose occurs on Boston Common, numerous media negative attention is placed on Boston and Cambridge programs, AHOPE is shutdown for several days because of safety concerns. PACT program begins to distribute Naloxone under medical directors license. Boston Mayor calls for meeting of BPHC/AHOPE, CAB, and PACT to explore strategies. Distribution remains underground. Advocates begin working on legislation similar to the New Mexico legislation that led to narcan distribution but could not identify a legislator with the courage or will to take on the cause.

Media Shit Storm

2005 – Boston Herald front page photo No Response = Death Boston Herald Photographer captures this photo of man in process of dying from fatal heroin overdose. Would this of got the same response if it was someone having a heart attack? 2005 – Boston Herald front page photo

Media Shit Storm

2006 Active players: Underground Community City BPHC holds Public hearings on Naloxone distribution. BPHC and CAB staff visit SKOOP sites in New York, BPHC administrators visit sites in Baltimore, New York, and Chicago. BPHC implements Naloxone distribution. BPHC launches OD 800 line. Pharmacy Access bill passes and implemented in MA. Underground continues in North of Boston communities.

2007 Active players: Underground Community City State Former BPHC commissioner John Auerback is appointed as MDPH Commissioner. BPHC releases its six month report on Naloxone distribution program, project becomes part of regular programming in the BPHC. Naloxone protocol and distribution begins in Cambridge modeled after the BPHC program. State announces Naloxone pilot project, 5 sites are announced and program staff are trained. Underground is very limited at this time due to underground volunteers disbanding and pilot projects be up and running.

Massachusetts Department of Public Health funded Naloxone Programs Gloucester Lynn Boston Cambridge Provincetown Quincy Brockton Springfield Northampton Fall River First state funded programs began toward the end of 2007 in Boston, Cambridge, New Bedford/Fall River, Quincy, Lynn/Gloucester, Brockton, Provincetown/Hyannis, and Springfield/Northampton. Hyannis New Bedford 2007

Media in 2007 Programs expanded to 7 programs covering 12 sites

2008 Active players: Underground Community City State Underground is not really happening at this time. All pilot sites training and distributing Naloxone. CAB implements Naloxone training at both Danvers and Boston detoxes. ODP and Naloxone become part of all BPHC methadone treatment facilities. 15 communities receive MassCall2 funding from MDPH through a SAMHSA SPF-SIG to address fatal and non-fatal opioid overdose.

Media in 2008 There were 637 overdose deaths reported in both 2006 and 2007

MassCall2 15 Municipalities received funding through MDPH to build capacity to address fatal overdose Communities were chosen due to high OD rates All identified barrier of calling 911 as variable Most communities work closely with state funded naloxone programs Engaged law-enforcement, treatment providers, harm reduction personnel, and community members Only Massachusetts identified fatal overdose as a priority in their SAMHSA SPF-SIG as most states identified underage drinking. Communities used SPF Assessment (3 months), Capacity Building, Planning, Implementation, and Evaluation.

Good Samaritan Legislation Two GS bills were introduced in MA in 2008 Several groups advocated and lobbied legislators Both bills failed during this legislative session But we came close, some last minute behind the door dealings help to defeat bills

2009 Active players: Underground Community City State Revere Fire Dept and Quincy Police personnel are trained to carry and administer Naloxone as part of the State Pilot Program.

More Work to Do State report says deaths from opioid-related overdoses declined in 2008 By Vicki-Ann Downing Enterprise Staff Writer Posted Dec 19, 2010 @ 06:00 AM BROCKTON — “The overdose rate for the South Shore in 2009 was high and it was steady throughout the year,” said Dubois. “As a whole, 2010 was lower in the amount of fatal overdoses compared to 2009, but still too high.” That the governor’s report contained any information at all about deaths from drug overdoses – in addiction to cancer, heart disease, Alzheimer’s disease and diabetes – shows it “is still something that the Commonwealth deems to be a critical issue,” said Dubois. The report, based on statistics from the state Department of Public Health, showed 594 deaths from opioid-related overdoses in 2008, compared to 637 in both 2006 and 2007. The number of overdose deaths began to climb beginning in 1996, when there were 178, according to the state… State overdose deaths put at 594, first drop in 4 years

2010 Active players: Underground Community City State Underground is limited to one community as four new state programs begin

Massachusetts Department of Public Health funded Naloxone Programs Lawrence Lowell Gloucester Lynn Boston Provincetown Cambridge Quincy Holyoke Worcester Brockton Springfield Northampton Fall River In 2010 the State expanded into four additional communities; Lowell, Lawrence, Holyoke, and Worcester. The selected communities reflect cities with the highest rate of fatal and non-fatal overdose. Hyannis New Bedford 2010

Good Samaritan Legislation Good Samaritan Coalition formed Three GS bills introduced, another with a provision to address GS Garner community support Parent support groups Treatment and Recovery Community support Community forums conducted Students for Sensible Drug Policy Momentum grows for another Good Samaritan push and growing support from many quarters

2011 Active players: Community City State Learn To Cope members are trained as MDPH approved Naloxone trainers. Gloucester Police and Fire Dept personnel are trained to administer Naloxone as part of the State Pilot Program.

Screening Brief Intervention, Referral to Treatment (SBIRT) Eight Hospitals funded by MDPH for SBIRT Harm reduction strategies have been incorporated Motivational Interviewing (MI) HPA’s provided with training to train and enroll participants into state naloxone program HPA’s are enrolling patients who present at hospitals with opioid or overdose isssues.

Learn To Cope Support group for family members and loved ones of opioid users Five groups in eastern MA 14 members are approved MDPH Naloxone trainers Training of peers take place at their meeting’s Parents have used Naloxone to reverse OD’s.

2012 Active players: Community City State Good Samaritan legislation is passed, overdose vigils and remembrances take place in several communities,

Challenges Slow pace Needed legal backing and buy-in from “authorities” before could become legitimized Getting over ego stuff Staff buy-in to risks of distributing naloxone pre-pilot years Negative press/media Limited research made it difficult for public health people to buy in Challenges that faced all who took part in this initative will be discussed.

Looking Forward Expanding into more ER’s (SBIRT) Expanding first responder involvement Persons in Recovery and Treatment become partners ODP being incorporated into standards of care for short-term drug treatment Research possibilities that contributes to the case being made for OTC sale of Narcan FDA approval of nasal Narcan use ODP being incorporated into the DOC Education on Good Samaritan laws Possibilities for the future will be explored and discussed.

Successes Collaborative process between underground and funded programs Philosophy shift in State (BSAS) Acceptance of harm reduction philosophy by treatment programs, parents of users, etc. Buy in from many stakeholders to legitimize naloxone distribution Good Samaritan Law passed Lives saved Possibilities for the future will be explored and discussed. Good Samaritan bill included Naloxone language protecting individuals and physicians who prescribe naloxone.

More Successes 2006-2012 Enrollments 15,000+ individuals 300 per month 1500+ reported reversals 30 per month RFD has more than 70 OD reversals Possabilities for the future will be explored and discussed.