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Naloxone Expansion Programs

In the past two decades in the United States, the number of deaths from overdose not only has risen but has surpassed the number of deaths from car accidents. The use of the emergency medication, naloxone, can reverse the effects of opioid overdoses and reduce the incidences of morbidity and mortality related to opioid overdoses. There is some evidence that naloxone distribution and education programs can reduce opioid overdose death rates in communities, though additional research is needed.

Naloxone is a type of medication that can reverse an overdose caused by opioids. Naloxone works on illicit opioids like heroin and on prescription opioids like oxycodone and hydrocodone, but it will not reverse an overdose caused by non-opioid drugs. The medication works by reversing the depressive effects that opioids have on the nervous and respiratory systems.

Naloxone can be administered by anyone who has received training, from healthcare professionals like emergency responders and primary care providers to laypeople such as family members. Naloxone is typically administered via injection, but a nasal spray version is also available. While both methods of administering naloxone are effective, one program reported greater willingness for non-medical professionals like law enforcement to administer the life-saving drug when it was available as a nasal spray, as they were hesitant to administer an injection.

Research indicates that harmful use of nonmedical prescription opioids is disproportionately high in rural areas. Rural areas have reported an increase in overdose deaths due to nonmedical use of prescription opioids, with death rates attributed to prescription opioids highest in states with large rural populations, including Kentucky, West Virginia, Alaska, and Oklahoma. These disproportionately high rates of overdose in rural communities suggest an urgent need to expand naloxone programs by providing both education about and access to naloxone.

Rural programs implementing naloxone distribution programs frequently cite the importance of contracts and memoranda of understanding with partnering agencies like pharmacists, primary care providers, law enforcement, hospitals, and other key community stakeholders. Programs also referenced the importance of community buy-in and participation in the development of naloxone distribution programs. By getting the community involved in the beginning stages, rural programs report being able to better address the attitudes, perceptions, and stigma associated with working on issues related to opioid use disorders.

In 2015, the U.S. Department of Health and Human Services developed a pilot program with the Federal Office of Rural Health Policy called the Rural Opioid Overdose Reversal (ROOR) Program. Eighteen grant recipients in 13 states were awarded $100,000 over a one-year period to reduce opioid overdose in rural communities through the purchase and placement of naloxone kits to reverse the effects of opioid overdoses.

Good Samaritan Drug Overdose Laws: Good Samaritan drug overdose laws can also help to support naloxone expansion programs by providing immunity from criminal prosecution to individuals experiencing an overdose or their companion to request emergency services during an overdose in an effort to prevent overdose-related fatalities. Experts recommend using Good Samaritan drug overdose laws as a way to reduce overdose deaths.

Good Samaritan drug overdose laws provide immunity from criminal prosecution to individuals experiencing an overdose or their companion to request emergency services during an overdose in an effort to prevent overdose-related fatalities. These laws apply beyond opioid overdose. Various factors may prevent individuals from seeking help during these situations. Adjustments to laws and other policies enable personnel to act without fear of negative consequences.

Two main categories exist under the Good Samaritan framework. The first type encourages the wider prescription and use of naloxone. It encourages that prescribers acting in good faith are allowed to prescribe naloxone to persons who may be able to use it to reverse opioid overdose by reducing the possibility of legal action against the prescriber and naloxone administrator. The second type encourages bystanders to seek medical help without fear of arrest or other adverse consequences. As of July 2017, all 50 states and the District of Columbia have passed legislation to improve naloxone access to community members.

Examples of Naloxone Expansion Programs

  • Project Lazarus: This North Carolina-based organization provides technical assistance to community groups and clinics on overdose prevention and opioid safety education. In addition to coalition building and community engagement activities, the Project Lazarus program has created toolkits and trainings designed for pharmacies, care managers, primary care providers, emergency department staff, law enforcement, and first responders on opioid overdose prevention.
  • Wabanaki Pathway to Hope and Healing: This project, funded by the Rural Opioid Overdose Reversal Program, created a partnership between Diversion Alert, a statewide program linking healthcare providers and law enforcement, with a coalition of five tribal communities in rural Maine. Naloxone kits were distributed within each tribal community and trainings were provided on the administration of the life-saving drug. Using Project Lazarus as a model, materials were adapted to be culturally appropriate to the tribal communities involved.
  • Project VIBRANT: This project, based in rural North Carolina at the Granville Vance Health Department and funded through the Rural Opioid Overdose Reversal grant program, conducted community-wide trainings on recognizing the signs of overdose and administering naloxone. Community members at risk of experiencing or witnessing an overdose, as well as first responders, emergency medical providers, and drug treatment counselors received training on and access to naloxone kits.
  • Project DAWN: Deaths Avoided With Naloxone: This community-based overdose education and naloxone distribution program from Ohio provides participants with education about overdose and training on how to administer naloxone. As of June 2016, Project DAWN has provided trainings to over 42 counties in Ohio.
  • San Luis Valley N.E.E.D. (Naloxone; Education; Empowerment; Distribution): Organized by the San Luis Valley Area Health Education Center, this Rural Opioid Overdose Reversal grant program provided naloxone access and education to six rural Colorado counties. Community stakeholders were trained in the administration of naloxone and were provided with naloxone kits free of charge after completing the training.

Considerations for Implementation

Layperson administration of naloxone is most safe when he/she has received training on the recognition of opioid overdose and on the appropriate administration of naloxone. Many states, but not all, have passed laws that make it easier for laypeople to dispense naloxone in an emergency. While many community programs may provide naloxone dispensing kits, the medication itself is still only obtainable by prescription. In late 2015, the FDA also approved a nasal spray version of naloxone, which had previously only been available in injectable form. With multiple formulations now available, increased availability and usage may follow.

Program Clearinghouse Examples

Resources to Learn More

Good Samaritan Drug Overdose Laws
Provides links to evidence of effectiveness for Good Samaritan drug overdose laws and examples of implementation.
Organization(s): County Health Rankings & Roadmaps
Date: 3/2016

Good Samaritan Overdose Prevention Laws Map
Interactive map that allows users to find Good Samaritan laws by state.
Organization(s): LawAtlas Policy Surveillance Portal

Law Enforcement Naloxone Toolkit
Serves as an educational resource regarding law enforcement use of naloxone. Topics covered include administering naloxone, law enforcement training, liability and risk, and more.
Organization(s): U.S. Department of Justice, Bureau of Justice Assistant National Training and Technical Assistance Center (NTTAC)

Legal Interventions to Reduce Overdose Mortality: Naloxone Access and Overdose Good Samaritan Laws
This report summarizes Good Samaritan Laws and the states in which they have been enacted. Findings support that as more Good Samaritan Laws have been passed, naloxone access has increased and theoretically decreased the amount of deaths due to opioid overdose.
Organization(s): The Network for Public Health Law
Date: 7/2017

Opioid Overdose Prevention Toolkit
A toolkit designed to educate individuals at the community level about opioid overdose and various strategies to help overdose prevention. It also provides resources for first responders and additional resources for communities.
Organization(s): Substance Abuse and Mental Health Services Administration
Date: 2018

Prescription Drug Overdose (PDO) Prevention for States
Describes the PDO program, which was designed to help states combat the high rates of prescription drug overdose.
Organization(s): Centers for Disease Control and Prevention

Project Lazarus Community Toolkit
A toolkit designed for community programs which provides information on creating community coalitions to address opioid overdose. It contains fact sheets designed for specific community sectors and information on naloxone prescribing and training in its use.
Organization(s): Project Lazarus
Date: 2014

Rural Healthy People 2020, Volume 1
Chapter 5 of this report, Substance Abuse Trends in Rural America, gives an overview of substance abuse data in rural communities, with an analysis of prevalence and disparities in rural communities.
Author(s): Kash, B., McMaughan, D., Hutchison, L, and Tan, D.
Citation: Rural Healthy People 2020, Volume 1, 73-82
Date: 2015