Drug overdoses are now the leading cause of death for people under the age of 50 in the United States. To stem this crisis, we need to devote substantial resources to evidence-based solutions that can make the greatest impact.
The majority of overdose deaths involve opioids, which means they could have been easily reversed by a timely administration of naloxone (brand name Narcan). Many people prefer to use a naloxone nasal spray as opposed to a less expensive injectable formulation, but at a cost of $75 for two doses, providing everyone in the country with intranasal naloxone (and refills) may be seen as too expensive. As such, it is prudent to prioritize who should be trained to use and provided with this life-saving medication. The obvious solution is to concentrate on people who use drugs and their families and friends, since they are most likely to be near someone who is experiencing an opioid-related overdose. Since drug use is illegal and stigmatized in the U.S., the biggest hurdles to dispersing naloxone to people who use drugs are locating them in a non-threatening way and providing training and naloxone when they have time and are willing to be trained.
Beginning in the late 1990’s, Dan Bigg at the Chicago Recovery Alliance started providing overdose education and naloxone distribution (OEND) directly to people who use drugs at their syringe services programs. Over the past two decades, over 300 syringe service programs have started providing OEND in the U.S. While syringe service programs are an excellent venue to locate people who use drugs and to provide trainings in a non-judgmental way, we need to expand the reach of OEND beyond these programs.
Because of our country’s 40-year long War on Drugs, about half of all people in jails and prisons have been incarcerated for drug-related offenses. Therefore, until policies and policing practices change, jails and prisons are prime locations to implement OEND: they are a good place to locate people who use drugs, and people have plenty of time to participate in training. Another reason for implementing OEND in jails and prisons is that people who were previously dependent upon opioids lose their opioid tolerance level during incarceration. As a result, once they are released, they can’t tolerate the same dose of opioids, which often leads to overdose. In fact, a 2007 study published by Ingrid Binswanger and colleagues in the New England Journal of Medicine found that in Washington State, people who have been recently released from prison are 129 times more likely than others to die from an overdose.
Currently, only a handful of jails and prison systems in the U.S. have implemented OEND programs. To determine whether the success of OEND at syringe services programs could be replicated in jail and prison settings, we partnered with experts from University of California Berkeley, the Harm Reduction Coalition and Kaiser Permanente Colorado to conduct an implementation science study to figure out how best to implement such programs in three San Francisco Bay Area counties. By engaging jails and prisons in these three counties, we identified barriers to and facilitators for implementing OEND programs in jails and prisons.
Based on this study, we developed strategies for developing, coordinating and evaluating OEND programs in jails and prisons. We found that it’s important to understand the jail/prison implementation climate, identify and engage key stakeholders, establish external partnerships and figure out how to obtain a steady source of naloxone. Coordinating an OEND program requires training facility and program staff, developing a plan for how to identify program participants and figuring out the logistics of distributing and storing naloxone. Finally, evaluation of OEND programs in jail and prisons involves planning, data analysis and documenting and communicating findings.
In an effort to make OEND programs easier to implement, we have created a primer that outlines how to successfully set up a program in jails and prisons. It is my hope that this facilitates the implementation of more jail- and prison-based OEND programs so that more people who use drugs are provided with the tools to reverse overdoses in their communities when they are released. Given the large number of people dying of overdoses domestically, these programs have the potential of saving many lives.
For more information on our primer or to discuss our harm reduction research in jails and prisons, please contact me.