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What Makes a Naloxone Program Successful? - Lessons from NC

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Programs are popping up all over the country to distribute naloxone, a medicine that reverses opioid drug overdose, to people who can use it to save lives. With all the different programs - some in urban areas, some in rural; some run by governments, some by nonprofits; some with large budgets and some with no budget at all - it might be difficult to sort through the information to determine what works best. To help, here is a short list of best practices that can be adapted to any program no matter its size, location, or budget.

1. Mobility - One of the sharpest differences we see in numbers of overdose prevention kits distributed and number of successful overdose reversals is fixed site v. mobile distribution. Mobile distribution models, in which outreach workers deliver naloxone to people at risk for overdose by meeting them in their homes, at work, on the street or at other frequented sites, are able to distribute far more kits than programs that have a fixed location where clients come to them. In High Point, North Carolina, for example, which has both a fixed site and mobile distribution, the fixed site dispensed five kits while the outreach worker dispensed 235 during the same three-month period. Other fixed sites have also seen distribution in the single or double digits over many months, while mobile outreach workers in the same area are able to reach hundreds of people. (Exceptions include when the fixed site has a large draw, such as a syringe exchange program).

The reasons for the success of mobile distribution have a lot to do with the behavior of people who use naloxone. The largest population of people who seek kits is active drug users. Active drugs users often stay hidden from mainstream locations and are unlikely to visit a fixed site naloxone distribution program such as a health department unless there is some other incentive such as syringe exchange. They also may lack the funds or transportation to seek out naloxone, especially in the US South and rural areas.

Another group of people at high risk for drug overdose death are those who have stopped using drugs for a while and think they don't need naloxone. Research shows that people who have stopped drug use are at highest risk of overdose if they start using again, so the people who don't think they need a kit are precisely the ones who need it most. Because they believe they won't need the kit, the majority of them won't make the effort to seek one out from a fixed site. However, an outreach worker who meets them in person and offers a free kit on the spot is more likely to have success at getting the kit into the hands of someone who will need it later, even if he or she doesn't realize it at the time.

2. Standing Orders - A few years ago, in most states naloxone could only be obtained by visiting a doctor for a prescription. Multiple barriers prevented this from happening, including lack of money or insurance for a doctor's appointment, lack of knowledge about naloxone, transportation issues, patients' reluctance to admit drug use and physicians' unwillingness to prescribe naloxone. But in recent years many states have allowed naloxone to become available through standing orders, meaning that one physician can write one prescription for multiple patients. NC Harm Reduction Coalition (NCHRC) for example, which instituted the first standing order for naloxone in community settings in the US South, has a standing order that allows any employee, even a contractor, to distribute naloxone to people at risk. This has allowed NCHRC to increase distribution exponentially and take naloxone directly to drug users.

3. Peer Distributors and Volunteers - The most successful naloxone distributors are drug user peers and people with close personal ties to the user community and an attitude of non-judgment. Because drug use carries so much stigma, users are often hard to reach except by those they know and trust. Utilizing the unique knowledge, connections and motivation of drug user peers is the most effective way to distribute naloxone. This is key - the best way to save lives from drug overdose is to give the kits to drug users themselves. Many well-intentioned organizations train their staff on how to use kits, but do not train clients. But most of the overdoses will occur off site, where staff are not present.

NCHRC, a small organizations of only two and a half full-time employees, has been able to distribute over 10,500 kits statewide in 18 months using a network of over 100 volunteer distributors scattered all over the state. The distributors are current or former drug users, family members of drug users, pastors, nurses, substance use counselors, methadone clinic personnel, and concerned community members. Not only does this network of people offer expertise that the small staff does not, it also allows NCHRC to have a presence all over a large state where trained distributors can meet one-on-one with people seeking naloxone and educate them on how to recognize and respond to opioid overdose. These distributors check in frequently with NCHRC staff to turn in log reports on distributed kits, to receive more kits and for guidance and resources.

NCHRC has also had great success in reaching people by working with methadone clinics. Because drug users come back to the methadone clinics on a weekly or even daily basis, this model provides outreach workers the opportunity to check back with people who have received a kit to see if the kit was used, leading to more accurate reporting results. In North Carolina, the two cities with by far the most reported reversals are not necessarily the areas with the highest overdose rates, but the ones where peer distribution has been most successful. In Asheville, (154 reversals) naloxone distribution is accomplished almost exclusively through methadone clinics, while in Greensboro (112 reversals) a strong network of drug user distributers has allowed the site to flourish.

4. Flexibility - Key to the success of any naloxone program is the ability to adapt to fluid conditions. The face of drug overdose keeps changing, users are often transient, and public policy and opinion are evolving. Good naloxone program coordinators keep their fingers on the pulse of these shifts and adapt the program to meet new changes. When the majority of drug overdose deaths shifts from prescription pain pills to heroin, the program must adapt. When younger and more naïve users are starting to inject drugs, overdose prevention advocates must meet to the new challenge. When the political atmosphere is finally ripe for reform, we all must be ready to act.