New ways to incorporate overdose prevention, response, and experience into substance use disorder treatment

A person experiencing an overdose doesn’t need the Big Book, motivational incentives, or cognitive behavioral therapy. She certainly doesn’t need methadone or a urine drug screen. That person needs oxygen and/or naloxone.

Although addiction treatment providers are in the commendable business of offering life-saving psychosocial and pharmacological therapies to people with substance use disorders, can they include overdose prevention training and naloxone in their arsenal?

A new guide says yes. And it offers lots more information in the way of how, where, and why.

How to do it

Alice Bell of Prevention Point Pittsburgh

Alice Bell is one of the authors of the new guide “Opioid overdose prevention and related trauma: incorporating overdose prevention, response and experience into substance use disorder treatment.” She has overseen overdose prevention training in greater Pittsburgh since 2002.

“Including overdose prevention and naloxone in [addiction treatment] programs seemed like such a no-brainer for me,” she said. “But as some programs started to really consider it and I had a chance to talk to providers in greater depth to hear some of the obstacles and concerns, I came to see that it is more complicated than it seemed to me on the surface.”

As a result, Bell and co-author Maya Doe-Simkins compiled a how-to guide customized specifically for addiction treatment providers.

“A holistic treatment and recovery approach means addressing overdose prevention throughout the continuum of care, remembering those who did not survive, and recognizing the imprint of trauma for many who did survive,” argue Bell and Doe-Simkins. But what does that actually look like?

Maya Doe-Simpkins of Heartland Health Outreach

Maya Doe-Simpkins of Heartland Health Outreach

Here are a few models:

  • Treatment staff provide all overdose education/naloxone distribution (OEND) for clients on-site
  • People from an outside organizations provide OEND on-site at the treatment program
  • Treatment staff provide education on-site, referrals to obtain naloxone off-site
  • Outside organization recruits patients and offers OEND in the geographic vicinity of a treatment center

Dr. Alex Walley illustrated the advantages and disadvantages to each of these models in his 2013 presentation to the Allegheny County Overdose Prevention Coalition. His presentation applied to methadone and detox providers, but the ideas hold true for a variety of treatment providers.

Walley Image

The guide encourages treatment providers interested in overdose prevention to consider which model would be best for the environment where they work as well as which is most likely to be implemented.

Where to do it

Overdose education can be incorporated throughout the continuum of care. The guide illustrates these opportunities, provides a rationale for addressing overdose at each point, and even includes sample language for treatment centers to use. Click on the image below to download and share it.

OD Prevention in Treatment

Why to do it

Of the over 40,000 people who died of a drug overdose last year in the United States, how many had passed through the doors of a treatment facility? I’m not sure. Neither are the authors of “Opioid overdose prevention and related trauma,” although–like me–they speculate that a lot of those who died had been to treatment at least once.

A study of staff from several different models of substance use disorder treatment programs found that between 38% and 45% had witnessed an overdose in their lifetime.

Of course, the same people probably passed through grocery stores and movie theaters, but the relationship you have with an addiction counselor is different from the one you have with your grocery bagger. In treatment, the issue of substance use is already explicitly on the table. A therapeutic alliance may be established. This means that treatment providers have an important opportunity to intervene and save lives.

Perhaps a surprising reason to provide overdose education and naloxone to clients is to increase their recovery capital. Dr. Jana Burson, who treats opioid use disorders using methadone and buprenorphine (and writes a great blog about it), has observed this transformation among her patients.

“Naloxone, of course, changes the life of the person who overdosed, but it also changes the life of the person who administers it,” she told me. “It’s awesome to watch the change occur in the person who saved a life. Suddenly this person, who received verbal and non-verbal messages all his life that as an addict, he was an unworthy drain on society, has become a hero who saved another human. That can be a powerful agent for change.”

And throughout the guide, Bell and Doe-Simkins argue that an organization needs to address overdose in some way in order to be trauma-informed. Incorporating discussions of overdose experiences and education about how to prevent future overdoses acknowledges the trauma of an overdose, fatal or otherwise.

Dr. Shannon Allen, addiction psychiatrist at JADE Wellness Center in western Pennsylvania, contends that virtually all of her clients have known someone who has overdosed. “And it’s really hard for them to talk about,” she said. “It’s a huge issue that isn’t being addressed and this is going to start opening that up for discussion and hopefully lead to helping patients through these tough times and memories and grief.”

“Read the paper. People are dying.”

Bell, who is also a mental health therapist, describes working with parents “who feel they don’t have a right to grieve” the loss of a child to overdose because the death was somehow a matter of choice.

“I’ve also heard from people who’ve lost friends that they sort of have gotten the message that ‘if you chose to be involved with people who used drugs, overdose death is just part of the life,’ and also that they don’t have the right to feel grief,” she said.

Addressing overdose and associate trauma is is not simply for the clients’ sake: a study of staff from several different models of substance use disorder treatment programs found that between 38% and 45% had witnessed an overdose in their lifetime.

Lucy Garrighan, CEO of JADE Wellness, suggests that treatment centers have more than the opportunity to prevent overdose–they have a responsibility.

“Some agencies are afraid of liability. I believe as agencies we should be more afraid of not helping someone,” she said. “This liability issue, I don’t know where this comes from. Read the paper. People are dying.”

Who’s doing it

JADE Wellness Center has been working with local pharmacies to stock naloxone and connecting individual patients with naloxone prescriptions on an as-needed basis.

According to Allen, “As soon as we can figure out how to get these kits available, we’re going to start a group [on overdose prevention] that everyone participates in at admission, as part of orientation. It may not be right at intake, which would be preferable, but it will certainly be within the first week. One of our clinical staff members will lead it.”

And within the next 60 days, Gateway Rehab will begin providing overdose education and naloxone to families on its main campus in Aliquippa. Naloxone will also be made available at its other program locations.