Saving Lives with the Opioid Overdose Prevention Program In Clark County, WA

State: WA Type: Model Practice Year: 2016

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Opioid overdose has become the leading cause of accidental death in Washington State.  In Clark County, the opioid-related death rate has increased by over 40%, and opioid-related hospitalizations have increased by over 200% in the last 10 years.  A local overdose assessment survey revealed that heroin is the primary drug of choice for 70% of CCPH’s Harm Reduction clients. Among those clients who use heroin, 63% reported using prescribed opiates before being hooked on heroin. Mortality and hospitalization statistics, as well as local community survey findings highlighted the need for addressing opioid overdose in our community.  

 The Overdose Prevention Program was developed in Clark County, WA following the passage of the Washington State Good Samaritan Law which legalized the prescribing, dispensing, possession, and use of naloxone for persons at risk of experiencing or witnessing an opioid-related overdose.  The law allows a prescriber to authorize a non-medical provider (health educator, volunteer, etc) to distribute naloxone. 

 To implement the program, CCPH developed a policy, protocol and standing order in which CCPH’s Health Officer authorizes staff to distribute naloxone at the HRC.  HRC staff and volunteers,  trained as “Overdose Prevention Educators”, are authorized to distribute and administer naloxone to persons at risk of experiencing or witnessing an opioid overdose.  

 CCPH developed an “Overdose Prevention & Naloxone Training” curriculum that Overdose Prevention Educators use to train clients as Overdose Responders.  The training includes overdose prevention techniques, recognizing signs and symptoms of overdose, calling 911 and education about the Good Samaritan Law, rescue breathing, naloxone storage, carrying, and administration, and post-overdose follow-up and care. A take-home naloxone kit is dispensed to Overdose Responders who are authorized to possess and administer naloxone to any persons (friend, family, partner, etc.) experiencing an opioid overdose.

 In the first 18 months, we met all of our objectives by successfully enrolling and educating over 350 individuals, distributing over 900 naloxone kits, and documenting 155 overdose reversals.  Our program was successful because of strong support from CCPH’s leadership, Clark County’s Board of Health, law enforcement, and many community partners who serve high risk populations. 

 The public health impact was a reduction in opioid-related overdose mortality, as well as increased awareness and education community-wide on an issue that affect a vulnerable and stigmatized population.

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Clark County Public Health
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Saving Lives with the Opioid Overdose Prevention Program In Clark County, WA
Clark County, in southwestern Washington State, borders the Portland, Oregon metropolitan area. Home to about 442,800 people, Clark County is largely suburban, with pockets of denser urban development and rural outlying areas.  Vancouver, population of about 167,000, is the largest of eight cities/towns in Clark County.  Clark County’s population is predominantly white, non-Hispanic (85%), and about 8% of the population is Hispanic.   About 15% of families with children in Clark County live below the Federal Poverty Level.  Clark County Public Health (CCPH) has operated a syringe exchange program within its Harm Reduction Center (HRC) since 1991.  The program uses proven harm reduction strategies to encourage intravenous drug users to reduce the risk of communicable disease transmission and to promote health in themselves, their families, and their communities.  The Harm Reduction Center (HRC) offers clients a safe, non-judgmental place to access resources, receive health education and counseling.  Opioid overdose has become the leading cause of accidental death in Washington State.  In Clark County, the opioid-related death rate has increased by over 40%, and opioid-related hospitalizations have increased by over 200% in the last 10 years.  Opiate overdose causes respiratory depression, and death usually occurs after several hours.  Others are often present but lack knowledge about overdose and are fearful of calling for help. Naloxone, a prescription medication, is an opioid antagonist that can reverse an overdose within minutes.  It has no effect on someone who has not used opioids and has been proven safe and effective for decades.  Lay persons, can learn to recognize and respond to an overdose by administering naloxone. Research has shown that education and distribution of naloxone can prevent deaths from opioid overdose.  The objectives were to develop an overdose education, prevention and naloxone distribution program within the HRC.  The goal was to reduce opiate overdose mortality in Clark County.  The Overdose Prevention Program followed the passage of the Washington State Good Samaritan Law which legalized the prescribing, dispensing, possession, and use of naloxone for persons at risk of experiencing or witnessing an opioid-related overdose.  The law allows a prescriber to authorize a non-medical provider (health educator, volunteer, etc) to distribute naloxone.  To implement the program, CCPH developed a policy, protocol and standing order in which CCPH’s Health Officer authorizes staff to distribute naloxone at the HRC.  HRC staff and volunteers,  trained as “Overdose Prevention Educators”, are authorized to distribute and administer naloxone to persons at risk of experiencing or witnessing an opioid overdose.  Overdose Prevention Educators identify syringe exchange clients as eligible Overdose Responder candidates who fulfill the following criteria:  Current opioid users, individuals with a history of opioid use, or someone with frequent contact with persons at risk for opiate overdose Age 14 years or older Able to understand and willing to learn the essential components of overdose prevention, management, and naloxone administration.   CCPH developed an “Overdose Prevention & Naloxone Training” curriculum that Overdose Prevention Educators use to train clients as Overdose Responders.  The training includes overdose prevention techniques, recognizing signs and symptoms of overdose, calling 911, education about the Good Samaritan Law, rescue breathing, naloxone storage, carrying, and administration, and post-overdose follow-up and care. The Overdose Prevention Educators assess candidates on their understanding of the basic components of overdose response and certify successful candidates as Overdose Responders.  A take-home naloxone kit is dispensed to Overdose Responders who are authorized to possess and administer naloxone to any persons (friend, family, partner, etc.) experiencing an opioid overdose. Each participant completes an enrollment form before receiving training.  Information collected includes demographics, housing status, substance use history, and overdose risk factors, and overdose experiences.  When seeking a refill, Overdose Responders complete a follow-up assessment that captures the reasons for a refill, whether it was used to reverse an overdose, and the circumstances in which it was used.  In the first 18 months, we met all of our objectives by successfully enrolling and educating over 350 individuals, distributing over 900 naloxone kits, and documenting 155 overdose reversals.  Our program was successful because of strong support from CCPH’s leadership, Clark County’s Board of Health, law enforcement, and many community partners who serve high risk populations.  The public health impact was a reduction in opioid-related overdose mortality, as well as increased awareness and education community-wide on an issue that affect a vulnerable and stigmatized population. Website: http://www.clark.wa.gov/public-health/ http://www.clark.wa.gov/public-health/hiv/needle.html
Opioid overdose is the leading cause of accidental death in Washington State.  Opioid-related morbidity and mortality in Washington State and Clark County have significantly increased over the past decade.  In Clark County, opioid-related death rates increased by over 40%, and opioid-related hospitalizations increased by over 200% in the last 10 years. A local overdose assessment survey revealed that heroin is the primary drug of choice for 70% of CCPH’s Harm Reduction clients. Among those clients who use heroin, 63% reported using prescribed opiates before being hooked on heroin.  Mortality and hospitalization statistics, as well as local community survey findings highlighted the need for addressing opioid overdose in our community.  The population affected by opioid misuse and overdose risk includes people who use opioids, including those who use or misuse prescription opioids, and those who inject prescription and/or illicit opioids.  The focus of this program is to reach people who inject prescription or iliicit opioids, their family and friends who may witness an opioid overdose, as well as community partners and professional who serve this population.   CCPH’s Syringe Services Program serves over 1400 unduplicated clients.  Over a quarter are youth age 24 or younger, and about 60% are of clients are male.  85% of clients are White, 6% Hispanic, 4% Native Hawaiian or Pacific Islander, 3% AI/AN, and less than 3% are Black or Asian.  Syringe exchange clients statewide earn on average $584 per month (before taxes), and 62% have unstable housing (34% are homeless while 28% have temporary housing).  On average, clients report witnessing 2 opioid-related overdoses in the past year, and experienced at least 2 overdoses in their lifetime.  74% of clients expressed interest in receiving overdose prevention education and obtaining a naloxone kit.   In the first year and a half of the program, CCPH successfully enrolled over 350 individuals, distributed over 900 naloxone kits, and documented 155 overdose reversals. 80% of individuals receiving overdose prevention training were syringe exchange clients, 10% were professionals, including CCPH staff, partner organizations, and students, and another 10% of enrollees represented friends or family of opioid users. Over half of clients (54%) reported either being in detox, jail, ER, street/shelter, or taking a few days off for any other reason. Additional overdose risk factors reported by clients include: 31% Drink alcohol with opioids   35% Use sedatives or downers with opioids 76% Use heroin or other opioids ALONE 53% Use drugs in a public setting (like a park, alley, or public bathroom) In the past, community-based organizations in urban settings were primarily responsible for distributing naloxone to laypersons.  Jurisdictions like Clark County, with a mix of suburban and rural areas had limited resources and community support for addressing substance use and overdose risk.  Before implementing naloxone distribution, CCPH was only providing overdose prevention education, including how to recognize an opioid overdose, and making sure clients understood the Good Samaritan Law which provides immunity from prosecution for drug possession charges to overdose victims and bystanders who seek aid in an overdose event.   Our current practice of incorporating overdose prevention and naloxone distribution as a component of our comprehensive syringe services has allowed us to provide a potentially life-saving intervention to a substantial portion of our population at-risk of an opioid overdose. Having the county public health department convene this program was beneficial for gaining community support in many ways.  CCPH shared the need for addressing opioid overdose with the Board of Health, who understood and supported the value of syringe services in the community.  CCPH has maintained strong community partnerships, and during the development of this project, was able to gain strong support from law enforcement, chemical dependency treatment agencies, and homeless youth outreach.  As a result of these collaborations, a chemical dependency treatment counselor from a community substance use disorder program, Lifeline Connections, is currently onsite at the Harm Reduction Center one day a week providing outreach for their Sobering Unit, Detox and treatment services.  Another community provider, Yellow Brick Road/Janus Youth, which provides outreach to homeless youth, now refers clients to CCPH for overdose prevention.  In addition, safe syringe disposal sites are currently available at two additional locations:  Lifeline Connections and Yellow Brick Road. The Centers for Disease Control and Washington State Department of Health recommend naloxone distribution as a promising strategy to prevent opiate overdose deaths.  Additionally, the Washington State Board of Pharmacy supports making naloxone available to high-risk populations such as syringe exchange clients, and it supports collaborative drug therapy agreements that allow pharmacists to educate ‘friends’ of potential opioid overdose victims and provide them with naloxone.  The American Medical Association and the American Public Health Association both have policies supporting the availability of take-home naloxone.
Opioid overdose is preventable through education and naloxone intervention, a medication that reverses and opioid overdose.  In an effort to reduce overdose mortality in Clark County, Clark County Public Health (CCPH) proposed developing an Overdose Prevention and Naloxone Distribution program as a part of the County’s comprehensive Syringe Services Program.   The program aims to address opioid mortality by increasing awareness on the issue of substance use and overdose in our community through strong inter-agency partnerships, providing education on overdose prevention, distributing naloxone kits, and training overdose responders among those at highest risk of experiencing or witnessing an opioid overdose. The Overdose Prevention Program was developed upon the passage of the Washington State Good Samaritan Law which legalized the prescribing, dispensing, possession, and use of naloxone for persons at risk of experiencing or witnessing an opioid-related overdose.  The law also allows a standing order from a prescriber to authorize a non-medical provider (health educator, volunteer, etc) to distribute naloxone.   To implement the Overdose Prevention Program, CCPH developed a policy, protocol and standing order in which CCPH’s Health Officer authorizes staff to dispense naloxone at the Harm Reduction Center.  Harm Reduction Center staff and volunteers operating the syringe exchange clinic are trained as “Overdose Prevention Educators”, and are authorized to distribute and administer naloxone to person at risk of experiencing or witnessing an opioid overdose. Overdose Prevention Educators identify syringe exchange clients as eligible Overdose Responder candidates, who fulfill the following criteria: Current opioid users, individuals with a history of opioid use, or someone with frequent contact with persons at risk for opiate overdose (a person who might witness an overdose) Age 14 years or older Able to understand and willing to learn the essential components of overdose prevention, management, and naloxone administration.   CCPH staff and interns developed an “Overdose Prevention & Naloxone Training” curriculum for Overdose Prevention Educators to use when training clients as Overdose Responders.  The training takes from 20 minutes up to 1 hour, depending on questions asked by candidates, and includes: Overdose prevention techniques Recognizing signs and symptoms of overdose Calling 911 and The Good Samaritan Law Rescue breathing Naloxone storage, carrying, and administration Post-overdose follow-up and care The Overdose Prevention Educator assesses whether the candidates who complete the training understand the information and feel comfortable with the basic components of overdose response.  Successful candidates are certified as Overdose Responders.  A take-home naloxone kit is dispensed to Overdose Responders who are authorized to possess and administer naloxone to any persons (friend, family, partner, etc) experiencing an opioid overdose. Naloxone Kit contents include: Two 1cc vials Naloxone Hydrochloride (concentration 0.4mg/ml) Two 3ml syringes with 22g 1 1/2” needles Alcohol Pads One pair of gloves Rescue breathing mask Overdose prevention tips & instructions to use Naloxone Overdose Prevention Educators identify syringe exchange clients at least 14 years of age, at risk of experiencing or witnessing opioid overdose as eligible Overdose Responder candidates, who fulfill the following criteria: Current opioid users, individuals with a history of opioid use, or someone with frequent contact with opioid users, age 14 years or older Risk for overdose or likelihood of contact with someone at risk, by report or history Able to understand and willing to learn the essential components of overdose prevention, management, and naloxone administration The program was launched in April 2014, and has been active since then.  CCPH maintains strong community partnership for successful implementation and support of public health programs. During the development of the overdose prevention policy and program, CCPH reached out to several stakeholders in the community to obtain support for the program.  CCPH’s Health Officer/Administrator reports to the Clark County Board of Health, a 3-member board comprised of County Councilors.  During the planning phase of this program, CCPH staff presented to the Board of Health on several occasions about the issue of opioid misuse, overdose trends, and the need for overdose prevention in our community.  The Board was receptive to CCPH’s proposal, and understood and supported the value of syringe services and overdose prevention.  CCPH also sought support from local law enforcement agencies, including the Sheriff’s department as well as local city police departments.  Since law enforcement officers often arrive at the scene of an opioid overdose before first responders, they have been extremely supportive of CCPH’s project and are expressing interest in overdose prevention training for themselves.  Engaging law enforcement has been important for the success of the program, particularly because of the opportunity to increase education and awareness about addressing the opioid overdose epidemic. This has also been an opportunity to engage law enforcement about implementation of the Good Samaritan Law in WA State, which legalizes naloxone distribution to laypersons, and provides immunity from prosecution for drug possession charges to overdose victims and bystanders who seek aid in an overdose event.  Another new partnership CCPH was able to form during the development of this program was with a local chemical dependency treatment agency.  This has been particular important for CCPH, since the risk of an opioid overdose increases exponentially when a person relapses after going through detox.  Lifeline Connections, a local treatment agency, provided an opportunity for CCPH to train treatment counselors on opioid overdose prevention and offered to refer clients to the Harm Reduction Center.  In addition, Lifeline Connections is currently onsite at the Harm Reduction Center one day a week providing outreach for their Sobering Unit, Detox and treatment services.  CCPH has also maintained a strong partnership with Yellow Brick Road/Janus Youth, which provides outreach to youth 24 years or younger who are homeless or at risk for homelessness.  Yellow Brick Road/Janus Youth now provides referrals to CCPH for overdose prevention.  These amazing partnerships not only enhanced the overdose prevention component of our syringe services, but both of these agencies are also offering two additional locations for safe syringe disposal to enhance CCPH’s efforts to reduce the risk of communicable diseases.  Additional collaborations have involved the schools as well as coalitions working with schools on issues of substance use prevention.  CCPH staff formed relationships with school district intervention counselors for overdose prevention training, particularly those based in the outlying areas of the county.  In addition, local youth prevention coalitions, as well as the county’s Substance Abuse Advisory Board, have engaged with CCPH and have coordinated training sessions for staff on overdose prevention.   During the planning stage of the overdose prevention project, CCPH applied for funding to AIDS United and was awarded a $10,000 supplies grant to fund naloxone kits for distribution at CCPH’s Harm Reduction Center.  In addition to the costs associated the naloxone kits, in-kind costs included staff time already dedicated to coordinating CCPH’s syringe services program.  The program operates 9 hours per week, and is primarily volunteer-operated, with 1 dedicated CCPH staff, and 15 volunteers.  Medical students and local university interns working with CCPH also contributed significantly to the implementation of the program. Volunteers, students and interns were involved in developing the educational curriculum, and are all trained as Overdose Prevention Educators who are authorized to train and distribution naloxone kits.
The program aims to address opioid mortality by increasing awareness on the issue of substance use and overdose in our community through strong inter-agency partnerships, providing education on overdose prevention, training overdose responders among those at highest risk of experiencing or witnessing an opioid overdose. The specific objectives were to develop an overdose education, prevention and naloxone distribution program within the HRC.  The goal was to reduce opiate overdose mortality in Clark County. Each participant completed an enrollment form before receiving training.  Information collected included demographics, housing status, substance use history, overdose risk factors, and overdose experiences.  When requesting refills, qualified Overdose Responders were eligible to receive the refills upon completion of a follow-up assessment.  Data collected upon refill requests captured the reasons for a refill, whether it was used to reverse an overdose, and the circumstances in which it was used.   In the first year and a half of the program, CCPH successfully enrolled over 350 individuals, distributed over 900 naloxone kits, and documented 155 overdose reversals.  Through this program, CCPH’s objectives to provide education on overdose prevention and reduce overdose deaths were met.  This program was successful because of strong support from CCPH’s leadership, Clark County’s Board of Health, law enforcement, and many community partners who serve at-risk populations.  Process measures collected throughout the program include demographic data on enrolled and trained individuals, as well as “saves” or reversals captured through the refill request form. Demographic and risk factor data collected on enrollees are described below: Who is getting trained? 359 individuals trained & enrolled Over 80% are syringe exchange clients About 10% are professional (Staff, partner orgs, students) Others include friends/family of opiate users Demographics 53% male 25% youth (age 24 or younger) Over half reported being either homeless or having temporary or unstable housing 19% homeless 30% temporary or unstable housing    Overdose Risk Factors: Over half of clients (54%) reported being in detox, jail, ER, street/shelter, or taking a few days off for any other reason 31% Drink alcohol with opioids   35% Use sedatives or downers with opioids 76% Use heroin or other opioids ALONE 53% Use drugs in a public setting (like a park, alley, or public bathroom)  Overdose History Lifetime OD 38% experienced 1 or more ODs in their lifetime 24% experienced 2 or more ODs in their lifetime 84% used heroin the last time they OD’d Of those, about half received naloxone from medical professional Witnessed ODs 43% witnessed ≥ 1 OD Only 15% received medical attention   Overdose Refills >900 naloxone kits distributed 155 reversals reported  Incidents Reported: Half of the incidents reported using 2 doses Most were used on a friend All involved heroin 12% called 911 Reasons for not calling included:       Felt could handle without medical help (11%) No phone (4%) Afraid of police involvement (4%)
We developed the Overdose Prevention Program in collaboration with staff, volunteers, and interns who played a key role in developing the educational training curriculum.  Based on pilot trainings conducted by staff and volunteers, a major lesson learned during project initiation was the length and comprehensiveness of the training.  Although the “curriculum” guide was comprehensive and thorough, staff soon realized that an efficient training session that was quick and engaging for clients would be critical to the program’s success.  Within a few weeks of initiation, we incorporated modifications into the training to accommodate clients with limited time and/or large groups.  The curriculum was modified such that a more in-depth session could be conducted if clients were interested and available.   In relation to partner collaboration, a major lesson learned was the potential of unconventional partnerships.  We were able to engage various sectors of the community and increased awareness and understanding of the opioid overdose problem and were able to offer training to clients, families, law enforcement, substance use treatment agencies, and schools.  Although we did not perform a cost-benefit analysis, national studies have shown that naloxone distribution to heroin users is highly cost-effective.  Through CCPH’s strong partnerships with law-enforcement, county & city officials, physical and behavioral health care providers, we are positioned to support and sustain  the Overdose Prevention Program.  CCPH intends to collaborate with local pharmacies to stock and dispense naloxone, and provide education and training, allowing us to reach a broader population at risk of opioid overdose (beyond syringe exchange clients, such as chronic pain patients using prescription opioid medication).   
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