While the opioid crisis has captured the concern of public health officials and the public, the epidemic is not evenly distributed. Rural communities are especially hard-hit, particularly areas with a large working-class population where dim economic prospects have led to dramatic increases in so-called “deaths of despair” (Case and Deaton, 2017). These communities bear a high share of opioid-related mortality, and also suffer from limited supports to treat addiction and related problems such as mental illness and chronic pain.
In Western New York, a task force of members from the rural counties of Genesee, Wyoming, and Orleans embarked on an initiative to reduce opioid deaths by specifically targeting the potential intervention points around overdose. An opioid overdose presents an opportunity for intervention because the opioid abuse comes to the attention of health care providers, and the individual may be motivated by the emergency to consider seeking treatment. However, this opportunity is often unrealized. While the overdose treatment drug Naloxone can reverse an overdose within minutes, Naloxone is not always available. When people in rural areas overdose, emergency responders tend to be further away than in urban or suburban environments; as such, overdose reversal may depend on bystanders who may not have Naloxone or be trained to use it. Second, survivors may decline emergency department (ED) treatment, and if Naloxone is administered by a bystander the survivor may never see a health care provider. Even when transport to a hospital occurs, the survivor may not seek addiction treatment. In fact, because Naloxone triggers a painful and unpleasant withdrawal reaction, the first impulse may be to obtain more opioids. Many hospitals have no protocols in place to treat withdrawal or refer to treatment, and many overdose patients are released from the hospital as soon as they are medically cleared and immediately resume opioid use.
The approach taken by the Task Force is multi-pronged and cross-sector, and has sought to involve the public, emergency responders, community hospitals, law enforcement, public health officials, and addiction treatment professionals to increase the number of people who overdose who 1) receive Naloxone, 2) present at the ED after overdose, and 3) are offered effective treatment, including peer support and opioid replacement therapy to prevent withdrawal, before leaving the hospital. A unique feature of the Task Force initiative is that it is cross-county, allowing the sharing of resources between counties and collaboration between agencies and providers across county lines. The Task Force is supported by a grant from the Greater Rochester Health Foundation.
The project’s approach to increasing overdose survival begins with an ambitious plan of community education around Naloxone administration. Providers of Naloxone training throughout the tri-county area participate in a sub-committee on Naloxone and have developed a common curriculum which all have agreed to use. Community members are recruited for trainings, as are emergency medical providers and law enforcement agencies. Family members of people who use opioids, and especially who have survived overdose, are often offered one-on-one informal trainings at the scene of an overdose or at the hospital. Trainings include a distribution of Naloxone kits to participants.
The Naloxone trainings are also used as a vehicle to increase the percentage of overdose survivors who are transported to a hospital ED. The common curriculum adopted by all trainers in the tri-county area includes a module emphasizing the importance of transport and medical follow-up and offering strategies to help encourage survivors to go to the ED. The Task Force has produced a 3-minute video on this topic and has incorporated it into the curriculum as of August 2019.
The third part of the Task Force initiative is centered on enhancing the capacity of hospitals to effectively care for overdose survivors. The Task Force worked with the three community hospitals in the region to implement a screening protocol for opioid use disorder (OUD) at ED triage and a three-pronged approach for the treatment of OUD in the ED. This approach includes contacting a Peer Recovery Advocate (Peer) to meet with the patient in the ED; providing the patient with a dose of buprenorphine for withdrawal symptoms and – if necessary – a bridge prescription of buprenorphine until the patient is able to be seen by a medication-assisted treatment provider; and encouraging Naloxone education and distribution to the patient and/or their support person by either contacting a Peer or providing a prescription for Naloxone that can be filled at a community pharmacy that offers subsidized Naloxone.
In addition to these targeted interventions, the Task Force developed a number of resources on addiction and recovery that are available to the community, including a web site, a call line staffed by Peers, and an ongoing slate of community events.
This is a three-year initiative which concluded its first year in April 2019. The Center for Human Services Research (CHSR) at the University at Albany was contracted by the Greater Rochester Health Foundation as an external evaluator for the three years of the project. Preliminary findings by CHSR were as follows.
The Task Force made great progress on their objectives during the first year. One of the greatest achievements was the robust implementation of the organized Naloxone training program. Nearly 1,200 individuals were trained in the three-county area in only a year’s time. Given an estimated population of only 110,859 adults in 2018, this equates to a striking 1 out of every 100 adults trained to use Naloxone. Early evidence from an evaluation of the training suggests the training has been effective in improving knowledge of key concepts (e.g., what to do first when you notice someone has overdosed) and increased behavioral intentions to administer Naloxone.
Another impressive achievement is that the Task Force has secured cooperation of all three local hospitals to adopt and implement protocols around the identification and intervention with ED patients who use opioids. The hospitals have added screening questions to their triage procedures to identify such patients, and with positive screens triggering the deployment of a Peer/Recovery Coach.
Events organized by the Task Force throughout the project year reached 896 community members and use of the call line for opioid information and referral has been steadily increasing from 6 calls in the first month to a cumulative total of 177 by the end of the project year. The project website, launched in March, logged 144 users in the first month. This brings the total count of community member contacts to 1,217 for the project year, not including attendance at the Naloxone trainings.
Opioid deaths in the region have decreased by 5% since the previous calendar year. However, this is consistent with decreases seen at the national level, and it is premature to conclude that this was a direct result of the Task Force’s work. Also, most of this was driven by a decrease in Genesee County, and small numbers make it difficult to discern whether this is a real trend. The death rate in Orleans County increased by 71%, which could reflect random year-to-year fluctuation in the data, but which bears further monitoring.
It is still early in the project to begin measuring outcomes, but early data show a promising start. Most of the stated objectives are on track, and systems are in place to capture key data points for evaluation. The work of the Task Force represents a systemic approach to the problem of opioid death by expanding potential intervention points across multiple systems (community members, families, first responders, hospitals, treatment providers, etc.) and raising community awareness about those potential intervention points.
The Center for Human Services Research (CHSR), located at the University at Albany, has over 25 years of experience conducting evaluation research, designing information systems and informing program and policy development for a broad range of agencies serving vulnerable populations.