Nevada Rural Opioid Overdose Reversal (NROOR)
- Need: To reduce the number of overdoses and deaths related to opioid overdose in rural Nevada.
- Intervention: The Nevada Rural Opioid Overdose Reversal (NROOR) Program, led by a Critical Access Hospital (CAH), furnished naloxone and provided education on prescription opioid use and overdose.
- Results: In total, 117 EMTs were trained on the administration of naloxone. EMTs greatly appreciated the naloxone training and the naloxone kits.
In Nevada, the number of ER admissions related to opioid overdose is 5 per 1,000 admissions. In rural Nye County, the number climbs to 7-8 overdoses per 1,000 admissions. Rural residents who overdose may not live close enough to a medical facility to receive treatment in time and, prior to October 2015, many basic-level emergency medical services (EMS) personnel did not have access to naloxone, a counteracting drug.
The Nevada Rural Opioid Overdose Reversal (NROOR) Program is a statewide partnership led by Desert View Hospital, a Critical Access Hospital (CAH) in rural Pahrump, to improve access to naloxone and provide training for first responders and for the loved ones of those at risk of overdosing.
NROOR came about in 2015, when Nevada passed Senate Bill 459, often called the Good Samaritan Law. This bill provided civil and criminal liability protections to anyone who helped prevent an overdose death and to healthcare providers who prescribed naloxone.
In addition, SB459 allowed for the furnishing of naloxone without a prescription from a physician. While naloxone still needs to be prescribed, a community organization can furnish naloxone kits without having a physician write a prescription for every person who receives a kit from this organization.
NROOR partnered with its state EMS office, which administered naloxone training to EMTs and paramedics around the state. The training covered both intramuscular needle and intranasal naloxone.
NROOR was funded by a Federal Office of Rural Health Policy (FORHP) Rural Opioid Overdose Reversal (ROOR) Grant and ended in August 2017.
- Distributed naloxone to EMS agencies staffed only by basic-level EMTs
- Enabled distribution of naloxone to at-risk individuals and family members
- Educated healthcare providers on prescription drug use and abuse as well as legislative changes pertinent to prescribers
- Provided public education and outreach about overdoses
In total, 117 EMTs were trained on the administration of naloxone and details on the new legislation and completed pre-test and post-test evaluations to measure the change in attitudes, knowledge, skills, and beliefs. The NROOR evaluation team found statistically significant improvements in the majority of evaluated areas. In other areas with marginal improvement, scores started high with little room left for improvement.
EMT services across Nevada reported being satisfied with training and the naloxone kits. Some services never had naloxone on hand before, so they were grateful for NROOR's paying for and providing kits. One volunteer EMT was especially thankful for the training: "Before, when we picked up an OD patient, all we could do was slap an oxygen mask on him, drive fast, and hope he made it."
In the final months of the grant period, the NROOR team began reaching out to rural EMS organizations to collect data on the number of naloxone administration and opioid overdose reversals. The team was surprised to learn that only a small portion of the naloxone provided had been used and is still currently investigating the disconnect between the data used to apply for the grant and the real-world demand for naloxone in rural Nevada.
The best data source available to the NROOR team back in April 2015 was hospital admission data, and the team's distribution plan was based on the number of opioid overdoses that were being reported in rural hospital emergency departments. Rural EMS agencies reported transporting very few suspected opioid overdoses during the two years of the grant period, and there were several doses of naloxone nearing expiration as the program came to a close. Fortunately, the State Chief Medical Officer was able to find urban-based nonprofit organizations to distribute the unused naloxone before it expired.
Since NROOR was intertwined with SB459, program coordinators were unable to implement certain parts of the program until the corresponding piece of legislation was solidified.
As stated above, one of the major barriers was accurately identifying the correct number of naloxone kits to rural EMS agencies. The State Health Division has improved the quality of the data since the NROOR team members initially applied for this grant, but they are still working on establishing a reporting system that can provide more real-time data on opioid overdoses.
Despite the passing of SB459, many prescribers worried that they might face a malpractice suit if they prescribed naloxone, especially a blanket order written for an organization instead of an individual. Other prescribers saw naloxone as enabling a patient with substance use disorder.
Some headway has been made in educating prescribers on the best practice of co-prescribing naloxone with opioids, but the progress has been slow. Lessons learned from NROOR helped inform decisions about planning the Opioid State Targeted Response (STR) grant for Nevada, though, and co-prescribing naloxone and more real-time, on-demand naloxone distribution will be major changes for the state.
Look into your state's existing legislation. Legislation might already exist that allows communities to work within a process that's already established. If there's no current legislation, contact your state medical officer, since this person can write a statewide order allowing communities to furnish naloxone under the state medical officer's license.
With the 21st Century Cures Act, every state has received funding to combat the opioid epidemic, and many states have brought this issue to the forefront of their efforts. There's a high likelihood that there is similar legislation either passed or soon-to-be-passed that will allow interested parties to replicate this model. Additionally, there are many organizations in each state partnering with state agencies on the Opioid STR grant and they may be excellent resources for organizations who want to collaborate on programs like this.
Chris Marchand, MPH, Project Director
Nevada Rural Opioid Overdose Reversal (NROOR) Program
Emergency medical services
Emergency medical technicians and paramedics
Illicit drug use
Prescription drug abuse
November 22, 2016
December 8, 2017
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