1. Strategies for Incorporating OD Prevention Into Your Work Eliza Wheeler Drug Overdose Prevention & Education (DOPE) Project Harm Reduction Coalition 510.444.6969 x 16 wheeler@harmreduction.org

2. Overdose Prevention & Naloxone Distribution Programs in the U.S. The earliest naloxone distribution began in 1996 and some programs started as recently as this year. States authorizing naloxone distribution: New York, New Mexico, Massachusetts, Illinois California has passed legislation to provide additional liability protection in 7 counties as a “pilot.” Cities, counties, local health departments, and individual programs have implemented naloxone distribution.

3. Overdose Prevention & Naloxone Distribution Programs in the U.S. As of November 2010, there were 189 sites where naloxone distribution was happening in 15 U.S. States and the District of Columbia. 67 % distribute 10ml vials of naloxone 42% distribute 1ml vials of naloxone 17% distribute 2ml Intranasal naloxone **Percentages equal more than 100% because some programs distribute multiple formulations of naloxone, or have had different types throughout the years.

4. Overdose Prevention & Naloxone Distribution Programs in the U.S. Between 1996 and June 2010, a total of 53,339 individuals have been trained and given naloxone as a result of US naloxone distribution programs. Programs have received reports of 10,194 overdose reversals using naloxone. 38,860 units of naloxone (all types) have been distributed during the last year, from July 2009-June 2010.

5. Common barriers to implementing an OD Prevention Program: Liability concerns Resources and time Agency policies Community opposition Ideological differences, lack of buy-in to Harm Reduction model

6. Common concerns and criticisms of OD prevention programs: Drug users are not capable of recognizing and managing an OD with naloxone The person who gets naloxone will be violent upon OD reversal Naloxone access will postpone peoples’ entry into drug treatment Naloxone access encourages riskier drug use

7. Integrating overdose messages Informal conversations that explore the context of drug use (i.e. do you use alone in your hotel room? Do you have friends who live nearby who know you use?) Adding assessment questions about overdose risk Including OD prevention as part of treatment plans/goal setting/discharge planning Posting OD-related messages (i.e. “Ask me about OD Prevention”)

8. Integrating Overdose Messages How do we talk with participants about their overdose risk or history of overdose? How do we provide overdose education in our setting(s)? Are there any programmatic barriers to communication (i.e. abstinence requirements, clients fear losing services if they disclose drug use, staff attitudes)? Is staff prepared to discuss harm reduction options with participants?

9. Providing OD Response Trainings Overdose prevention and response trainings can be done even if you are not yet able to distribute Naloxone Education on Rescue Breathing, calling an ambulance and other basic first aid response can be lifesaving Incorporate into existing group meetings and one- on-one interactions with participants Cost: staff time and printing materials, optional: rescue breathing mouth shields and rescue breathing dummies

10. Overdose Prevention, Recognition, and Response Training

11. Overdose Prevention, Recognition, & Response Trainings Can be done in various settings and using different models 10 minutes  60 minutes in length Depends on setting and experience of trainees Groups, pairs, individuals

12. Components of a Training 1. What is an overdose? 2. What causes an overdose? 3. Prevention messages 4. Recognition 5. Response 6. Aftercare

13. Naloxone Distribution Can we do it?

14. How is naloxone distributed? Distribution—programs obtain supply of naloxone and distribute to participants without prescriptions or medical provider oversight. Standing Order—issued by Health Department or physician to empower health care providers like nurse practitioners or trained outreach staff to distribute naloxone Prescription—program has medical provider sign off on a prescription for individuals who participate in a training and complete a short medical history/clinical registration form, health care professional must be present or available to sign prescriptions.

15. Pros and Cons of Distribution: Pros: Gets naloxone to the people who need it, without having to wait for “official” approval. Less paperwork, lower threshold Cons: Limited resources or funding to support program or purchase supplies Potentially inconsistent supply of naloxone Could put program and/or individuals distributing naloxone at risk for “practicing medicine without a license.” Could put program participants at risk for arrest for carrying prescription medication without documentation that it was prescribed to them

16. Pros and Cons of Prescriptions: Pros Protects participants from arrest for possession of a prescription drug without a prescription Documentation (paper trail) protects prescribing medical professional in terms of liability Cons Higher threshold (more paperwork required) Some medical providers still wary of providing naloxone in this manner Technically, provider must be present when naloxone is distributed, which requires time and resources Limited availability of providers can mean limited times that naloxone can be distributed.

17. Pros and Cons of Standing Orders: Pros Allows programs more freedom to distribute naloxone without the need for a medical professional on-site at the time of the trainings In states like Massachusetts, the Standing Order actually empowers NON-medical staff (i.e. NEX workers) to distribute naloxone Cons Unclear if Standing Orders are legally feasible for naloxone distribution, has not been legally “tested.” Medical providers can be skeptical of using Standing Orders and may want more oversight of the program if their license is on the line

18. Start a Naloxone Program! Identify the scope of the overdose problem in your community (what drugs, who, where, etc.) Find a medical director or licensed physician that is willing to prescribe naloxone (cite research, enabling laws and put in touch with currently prescribing doctors and medical directors). Purchase naloxone (with MD’s license number, through pharmacy or health department) and other supplies for kits.

19. Start a Naloxone Program! Train program participants, satellite exchangers, peer educators, outreach workers, health educators, etc. who can do the overdose prevention and response trainings. Work on getting community buy-in, especially first- responders like ambulance workers and police to prevent confiscation and harassment Network with prisons, drug treatment, parents groups, etc. to expand distribution

20. Considerations: Given your agency's facilities, policies, and staff, what are the potential barriers to developing an overdose prevention plan? What training would your agency need in order to put your plan into action? What resources do you already have (space, staff, time, photocopier, etc.)? And what do you need?

21. Thank You Eliza Wheeler DOPE Project Harm Reduction Coalition 510.444.6969 x 16 wheeler@harmreduction.org