You Can Be the Difference: Coming Together to Implement an Overdose Prevention Program in Boston
Unintentional overdose is the leading cause of preventable injury death in Massachusetts. Boston sees by far the largest number of overdoses each year of any Massachusetts city; the ongoing opioid epidemic continues to affect every Boston neighborhood and community at alarming rates. As part of a comprehensive response to the public health emergency, the City of Boston, led by the Boston Public Health Commission, employs a team of Overdose Prevention and Naloxone Education experts. These first-class trainers developed a comprehensive, multimodal training package that offers free, in-person or online education on opioid overdose recognition and response, naloxone (medication to reverse an overdose) access information and distribution, and recovery services resources to a wide variety of audiences, including active users and their families, business owners, public library staff, college and university campus safety, and tourist destination security.
According to the Massachusetts Department of Public Health1, from 2012 to 2016, the number of confirmed opioid-related overdose deaths in Boston increased by 288% (from 70 to 202 deaths). However, the true number of overdose deaths is estimated to be even higher, and 2017 data are expected to greatly surpass those from previous years.
Fatal and non-fatal overdoses are occurring in a variety of public settings, from restrooms to alleys to dressing rooms. Traditional first responders - fire fighters, police and emergency medical services - are highly trained and equipped to deal with an overdose. But often there are bystanders who could respond to the scene first, and in the face of an overdose, every second counts. Many people do not realize that they can take simple, life-saving response steps. Opportunities for fast and effective response can be created by training non-traditional first responders such as librarians who serve guests who may be under the influence, business employees who monitor public restrooms, security staff who patrol highly populated buildings and stairwells, campus police at colleges and universities, people who use public transportation in particularly affected communities, or anyone who may come in contact with an individual who is experiencing an overdose.
Substance use disorders and overdose historically have been highly stigmatized and rarely talked about openly. Equipping the public with basic information on overdose response and recognition, paired with information on accessing recovery services resources, opens the door to conversations about addiction and recovery.
Delivering overdose prevention and naloxone education trainings to the public has proven to be an effective strategy in increasing knowledge of overdose recognition and response management in non-clinical settings2. In an effort to deliver trainings to a wide variety of audiences who may be at risk of witnessing an overdose, the Boston Public Health Commission utilizes a comprehensive effort that includes data surveillance, community outreach, and in-person and online training resources.
The team trains more than 200 participants from the greater Boston area per week, across sectors, to serve as de facto first responders as a means to reduce the number of overdose fatalities. In addition to staff and clients at homeless shelters and substance use treatment facilities, trainees include business and neighborhood association members, public librarians in fifteen Boston communities, staff at more than ten community health centers, hundreds of nursing and pharmaceutical students at the many Boston colleges and universities, construction companies and trade unions, and security teams at tourist destinations, hotels, and concert and sporting venues across the city. Outreach to neighborhoods and communities is driven by narcotic-related incident data monitored and reviewed by the Boston Emergency Medical Services, a critical partner in developing strategies.
Most people do not realize that they can have a powerful role in combating the opioid epidemic. Response strategies are easy to learn, and the knowledge of how to identify and respond to an overdose empowers those who may otherwise feel helpless. Trainees learn overdose prevention tips and gain access to treatment information that can be shared with family, friends, or neighbors, who may be afraid or uncomfortable to reach out for help or information. Overdose prevention trainings open a dialogue about stigma surrounding addiction and educates large audiences on how to recognize and respond to an overdose. These trainings provide the public with tools to be part of the solution and are necessary to address this public health emergency that is affecting all populations regardless of race, ethnicity, and socio-economic status.
The trainings provided by BPHC equip Boston Public Library staff with knowledge, support, and perspective from professionals in the field, providing options for situations when emergencies arise and much-needed context for the broader issues involved in Boston and beyond. , Assistant Manager, Neighborhood Services Boston Public Library
The team provides free in-person trainings and hosts an interactive online training, each offering the same information with their respective benefits. Utilizing experienced trainers (some with lived recovery experience), the one-hour in-person trainings allow for face-to-face personal interactions that are tailored to the needs of the audience, include a question/answer section, can lead to formidable cross-sector partnerships, and are responsive to changing drug-use trends. The training team distributes naloxone, the life-saving overdose reversal medication, for those who are likely to witness and respond to an overdose. All sites or organizations interested in receiving a training can submit an online training request form, which allows for easy and efficient scheduling.
For individuals or small groups interested in learning about overdose prevention and accessing naloxone, the team hosts weekly drop-in community trainings. To ensure a non-judgmental environment, these afternoon and evening opportunities require no registration or sign-in sheet. Family or friends of substance users, students in the neighborhood, concerned community members and residents from outside Boston participate in these trainings.
The online training3 provides the same information in a less time-intensive format. The e-learning opportunity was developed in response to feedback from businesses and organizations that have large workforces and may face shift, scheduling, or union issues. The online option allows individuals or employees to be trained in overdose prevention on their own time and at their own pace with an option to receive a Certificate of Completion at the end. Participants are encouraged to contact the team if there are remaining questions. The online course concludes with a built-in evaluation component. To receive their certificate, participants must complete the evaluation, which includes eight short questions designed for participants to provide feedback about the learning experience and submit suggestions for improvement. Responses are monitored regularly and are used to update and improve the training as needed. The addition of a printable handout version of the training is an example of participant feedback being used to strengthen the training experience.
Through a combination of data-driven outreach efforts, web presence and a reputation of authenticity, the Boston Public Health Commission Overdose Prevention and Naloxone Education team reaches over 200 participants from Boston and surrounding areas per week, equipping each participant with the knowledge and skills to recognize and respond to an overdose. Boston Emergency Medical Services data indicate a 24% increase in naloxone administrations across the city in 2016, findings which may be attributed to an increase in the availability and training in overdose response. Assuming naloxone availability will continue to improve, medication use is expected to increase in 2017.
Training Impact (July 1, 2015-October 1, 2017)
The team receives countless anecdotal notes of gratitude from participants who may be personally or professionally affected by substance use disorders and the opioid epidemic. For individuals who are living this reality, the opportunity to have face-to-face conversations with knowledgeable, empathetic trainers is powerful. On-site trainings at organizations across the city also offer opportunities for the team to connect with service providers and to build relationships to better coordinate recovery service efforts.
...it’s not just the skills training that has benefited us, it is the confidence build that staff have acquired to feel enabled and confident that they can respond calmly in a crisis and apply the skills they learned... , Director of Clinical Services, Upham's Corner Health Center
Stigma may generate negative feelings, attitudes or language-use from the general public toward individuals dealing with substance use disorders. Overdose prevention training is an evidence-based harm-reduction practice, but it has the potential to disinterest individuals who hold stigmatized beliefs. People may feel uncomfortable or choose not to engage in conversations or participate in training opportunities on this topic. When offered training in overdose prevention, some people may fail to understand their potential role in recognizing or responding to an incident. The trainers on the team are fluent in responding to the negative language sometimes used to describe people who use substances, such as “junkie” or “addict. “While they are not able to change all opinions or force people to respond to an overdose, trainings offer an opportunity to challenge people to be aware of their attitudes and behaviors, choose their words carefully, and educate themselves on the facts of substance use disorders.
As the rate of overdose and public attention to this topic increased, the team was flooded with training requests from organizations across sectors citywide. In an effort to best coordinate the volume of overdose prevention training requests and streamline the scheduling process, the team created an online training request form. The webpage gives basic information about what the training includes, and the easy-to-complete form asks for the requester’s contact information, available days and times, and a description of the audience. This process allows the coordinator to make an educated recommendation for the best training option for the individual or group.
Offering overdose prevention in several modalities – drop-in community trainings, organization-specific in-person trainings, online training module, short YouTube video – can remove the barriers that organizations face when it comes to training opportunities. The public online opportunity has been particularly helpful in eliminating barriers and improving accessibility to training.
Audiences from across sectors appreciate trainers with lived recovery experience, and lifting up the voices of people in recovery is an important mechanism for grounding their work in the face of a national news media that too often exploits the issue. It is also imperative that trainers recognize the lived experience of the audience and the decades-long epidemic that has affected urban areas long before it became a paramount public health topic. Thoughtful and knowledgeable trainers who are able to debunk myths and decrease stigma in a credible way make non-traditional first responders more willing to learn and respond to an emergency.
The team is committed to building relationships with organizations that have participated, and does so by providing refresher sessions and monitoring community needs. In addition, the coordinator keeps an ongoing list of all participating organizations, including contact information for follow-up. In an effort to expand and continue to reach more participants, the team monitors and adapts the promotion of training opportunities to different sectors and audiences. By thinking creatively and utilizing a combination of print materials and an online presence, new audiences are aware of trainings and can better understand how the information may fit into their work or personal life.
While in-person trainings may depend on staffing capacity and time, the online training opportunity offers a sustainable option for reaching audiences. Boston Public Health Commission, in partnership with Delvalle Institute, hosts a learning center website that serves as an inexpensive platform to house this training. The program budget includes a line for hosting and also includes funds for upkeep, which can be important for a sensitive topic such as this, which may need continuous updates.
1 Massachusetts Department of Public Health. Number of Opioid-Related Overdose Deaths, All Intents by City/Town, MA Residents January 2012 – December 2016. Available at: https://www.mass.gov/files/doc...
2 Siegler A, Huxley-Reicher Z, Maldjian L, et al. Naloxone use among overdose prevention trainees in New York City: A longitudinal cohort study. Drug Alcohol Depend. 2017; 179: 124-130. Available at: https://www.ncbi.nlm.nih.gov/pubmed/28772172
3 DelValle Institute. Overdose Prevention and Bystander Training. Available at: https://delvalle.bphc.org/course/view.php?id=659