What's Next After Naloxone?

By Tessie Castillo 01/11/17

Naloxone has saved countless lives from overdose, but first responders are finding themselves reviving the same people over and over again. How do we get people treatment post-naloxone?

What's Next After Naloxone Treatment?
We reversed the overdose, now what?

Over the past decade, as drug overdose deaths have surged across the United States, the popularity and accessibility of naloxone has risen as well. Nationwide the drug is available to emergency departments and paramedics, and in many states law enforcement and community members can also administer it to reverse the effects of opioid overdoses. But recently the use of naloxone has met pushback from some first responders who are frustrated with reviving the same people over and over again. To many, the question after a naloxone reversal becomes, “What now?”

In several areas of the country, first responders and other community members have already begun to answer that question. Recognizing that an overdose can be a good intervention point, some communities have launched programs that reach out to people who have recently overdosed to offer resources on overdose prevention and mental health or substance use disorder treatment.

In July 2015 the Township of Colerain, Ohio, started a post-naloxone outreach program under the leadership of their Director of Public Safety, Daniel Meloy. Under this program, every Wednesday morning, representatives from the Colerain Police Department, the Colerain Fire Department, and Addiction Services Council, a local mental health and substance treatment facility, meet to review all overdose-related police reports from the previous week. These representatives, called Rapid Response Teams, go out into the community to visit the homes where the overdoses have occurred.

“We knock on doors and ask to speak with either the person who overdosed or any friends or family,” says Shana Merrick, a social worker with Addiction Services Council who has been with the program since its inception. “We explain that we are not there to make an arrest, but to offer resources to keep the person healthy, safe and well. Most people open their doors and we talk about their situation and needs.”

In cases where the person is interested in help but does not have medical insurance, Shana helps him or her sign up for insurance, including Medicaid. For people who aren’t eligible for Medicaid or can’t afford insurance, the county has dedicated indigent funds to help pay for treatment costs.

“About 80% of the people we see eventually seek some form of treatment,” says Shana. “It’s not always right away, but if we build a relationship over time then they may contact us later on asking for help.”

According to Shana, one of the biggest challenges they face is treatment capacity. When all treatment beds are full, she enrolls people in intensive outpatient programs until a space opens up in a traditional treatment program. Many people are also enrolled in medication-assisted treatment programs. Another challenge is staying in touch with people who are transient and may move location or change numbers.

Shana and the Rapid Response Team are fortunate to have a number of resources available to people who seek treatment, but overdose prevention specialists such as Bernie Lieving, who works with Santa Fe Prevention Alliance in New Mexico on a similar post-overdose outreach program, have far fewer options.

“There aren’t a lot of substance use or mental health treatment services in our area where we can refer people,” says Bernie, who visits people who have recently overdosed each week, along with a paramedic from the Santa Fe Fire Department. “We do offer to help people find treatment facilities if they want, but during most of our visits we work with families to come up with an overdose response plan, offer naloxone and training on how to use it, and brainstorm about how to reduce the risk of another overdose. People are excited and respond well to us. No one has ever refused to let us visit.”

The Colerain and Santa Fe programs are good examples of how overdose prevention and post-naloxone intervention strategies are possible with or without the presence of local substance use and mental health treatment resources. Other states have programs that show how the role of law enforcement and first responders can vary as well. Mary Wheeler is the Program Director for the Healthy Streets Outreach Program, a harm reduction program that partners with police and fire departments in several cities outside Boston, Massachusetts, to conduct post-naloxone visits.

“The role of first responders in visiting the homes varies between geographic locations,” explains Mary. “In some departments they assign one or two specific officers to do follow-up visits with a harm reduction counselor. In other departments, they rotate officers or officers can volunteer so that a variety of different people have the opportunity to see the struggles that people are facing. In some places, it’s just the harm reduction counselor who goes out without an officer. It’s important to give law enforcement departments many options for participation.”

The three programs in Ohio, New Mexico and Massachusetts have several things in common. The first is that they report that the vast majority of people they visit are receptive to receiving information on overdose prevention, naloxone, and resource options for treatment and case management. In some cases, the person doesn’t request help right away, but follows up later on after a relationship has been established with the counselor or first responders who visited initially.

Second, these programs do not rely on outside funding. Instead, capacity is built within existing departments and agencies. Law enforcement and fire departments may choose to allow some officers and firefighters to spend a few hours a week visiting houses, while addiction counseling organizations dedicate some staff to visits and case management. This model makes post-naloxone programs replicable without the need for separate, dedicated funding sources.

Third, these programs are non-coercive. Overdose patients and their loved ones are offered resources such as naloxone kits, assistance with creating an overdose prevention plan, and help signing up for medical insurance or treatment options. This is important to keep in mind as other communities around the country discuss more coercive models, such as forcing people who overdose to choose between mandatory inpatient treatment or jail. It would take a separate article to go over the problems with coercive models, including cost, impracticality, civil rights violations, and evidence that non-consensual commitment to treatment significantly increases the chance of a fatal overdose later on. But suffice it to say that non-coercive programs are demonstrating that the vast majority of people are open to some form of assistance without being forced.

As communities explore options to offer resources to people post-naloxone administration, it is important to note that these programs are just one piece of a solution to a very complex issue. Everyone is looking for the “golden ticket” to do away with the problem of chaotic drug use and tragic deaths from overdose, but none of the proposed solutions—not naloxone, not post-overdose outreach programs, not more inpatient treatment, not injected medications that block cravings for opioids—is a panacea. The situations and needs of people who use drugs vary widely, as does resource availability in any given area. Post-naloxone visits will help some people but they need to be coupled with robust efforts in overdose prevention education, naloxone distribution, diverse treatment options, drug policy and criminal justice reform, and many other interventions. The questions we explore need to go much broader and deeper than “What’s next after naloxone?”

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Tessie Castillo is a writer and drug policy advocate in Raleigh, North Carolina. Her articles explore topics such as criminal justice reform, drug policy, and harm reduction. Castillo previously served as the Advocacy and Communications Coordinator for the North Carolina Harm Reduction Coalition (NCHRC), a statewide nonprofit that advances drug policy and criminal justice reform. During that time, she played a pivotal role in helping to legalize syringe exchange programs and expand access to naloxone, a medicine that reverses opioid overdose. Find Tessie at her website or on Facebook, TwitterInstagram, and LinkedIn.