Exploring Effective Post-Opioid Overdose Reversal Responses for Law Enforcement and Other First Responders

Daniel P. Meloy, Colerain Township Administrator and Director of Public Safety contributed to this article.

Introduction

Opioid use disorder is a chronic and relapsing condition, and the risk of overdose is likely to persist for a lifetime among those diagnosed.^[1] While physical tolerance—i.e., needing a greater dosage of opioids to achieve the same effect—increases with sustained use of opioids, cardio-respiratory tolerance does not. The increased dosage or even a return to previous dosage levels following a period of abstinence such as in jail, prison, detox or even treatment, places users at greater risk for overdose. Most opioid overdose deaths are accidental and individuals are at higher risk for overdose with the use of depressants, such as alcohol or benzodiazepines (Xanax®).^[2] Magnifying the number of overdoses in the United States is increased opioid misuse and the recent emergence of stronger opioids such as fentanyl, a highly accessible synthetic opioid drug with high potency and low production costs.^[3] The Fentanyl Safety Recommendations for First Responders provides unified, scientific, evidence-based recommendations so first responders can protect themselves when in contact with fentanyl.

Due in part to the widening use of overdose reversal medicine naloxone, non-fatal overdoses have become more common than fatal overdoses. Once per 100 heroin users die each year, with a ratio of 31 non-fatal overdoses for every one fatal overdose.^[4]

Naloxone: The Starting Point for First Responders

Naloxone can be administered to reverse signs of opioid overdose, which include respiratory depression, central nervous system depression, and constriction of the pupils.^[5] Naloxone (brand names Narcan® and EVZIO®) is a safe and effective antagonist medication, which can be administered nasally (Narcan®) or by auto-injection (EVZIO®). Naloxone works fastest when injected intravenously, but produces fewer adverse effects when injected into the muscle or inhaled.^[6] Although available since the early 1970s, expanded use occurred in the late 1990s. Naloxone is available by prescription in some states and over the counter (no prescription required) in others. Some states have enacted a standing order for naloxone, allowing for specified agencies to remain stocked with naloxone via their local pharmacies. In this case, the state is billed directly for the cost of the medication.

Naloxone is not a U.S. Drug Enforcement Administration (DEA)-controlled substance and has no abuse potential as it does not contain opiates. The drug remains effective in the body to reverse the effects of opioids for 45 to 60 minutes. Since the opioid-dependent person goes into immediate withdrawal following naloxone administration, this limited post-overdose reversal period requires special attention to ensure the person revived does not quickly return to opioid usage as a means to alleviate the pain of withdrawal.

Opioid withdrawal can be extremely distressing with multiple symptoms, which may include all or some of the following: vomiting, diarrhea, muscle pain, chills, sweating, tear secretion, runny nose, yawning, and increased blood pressure and heart rate.^[7] Complications due to opioid withdrawal can be life-threatening.^[8] In addition, the administration of naloxone to pregnant women may trigger withdrawal in the fetus. Immediately following naloxone administration, patients often appear angry and aggressive, due in part to the physical distress that is triggered by withdrawal.^[9] In addition, when painful withdrawal symptoms set in, patients often immediately seek opioid drugs for relief despite having just experienced a life-threatening overdose.^[10]

Naloxone administration is a harm-reduction strategy.^[11] Although a goal may be to end opioid misuse and sustain abstinence and recovery, naloxone is a critical tool to mitigate the ultimate immediate negative outcome—death. Research has demonstrated that access to naloxone is not associated with increased drug use. In fact, two studies on naloxone distribution by overdose prevention programs reported a reduction in self-reported drug use. After naloxone, a rapid connection to treatment and, if clinically indicated, the use of medications naltrexone, buprenorphine, or methadone can reduce cravings thereby stabilizing the person so they can enter treatment and get on the path to recovery.

Figure 1

Naloxone, overdose reversal drug

• Brand names: Narcan®, Evzio®
• FDA Approved: 2015
• How taken: Injection or nasal spray
• How often taken: Once, when experiencing overdose
• Cost: $20-$40
• Common side effects: Nervousness, restlessness, irritability, body aches, dizziness, weakness, diarrhea, stomach pain, nausea, fever, chills, goose bumps, sneezing, runny nose
• Administered by: Trained doctors, first responders (police, fire, paramedics), and laypersons
• Intended use: Reverse an opioid overdose

Police and other first responders, including fire fighters and emergency management technicians, carry naloxone to revive individuals experiencing an opioid overdose. The Bureau of Justice Assistance created a Law Enforcement Naloxone Toolkit for agencies in establishing a naloxone program. In addition, many states allow laypersons to access and administer naloxone. The North Carolina Harm Reduction Coalition, a national naloxone advocacy group, reported 1,214 U.S. police departments carried naloxone by the end of 2016. However, in Illinois, only 8 percent or 78 of more than 1,000 police agencies are known to be carrying naloxone.^[12] A 2016 survey of law enforcement in Illinois found 34 percent of responding police agencies reported no officers were trained to administer naloxone.^[13]

An Illinois law passed in 2015 naloxone authorized trained pharmacists and first responders to dispense naloxone.^[14] It also required state and local law enforcement agencies to establish policies for the acquisition, storage, transportation, training, and administration of naloxone [Public Act 99-0480]. In 2017, the Illinois Department of Public Health issued a statewide “standing order” for naloxone making it available for pharmacies and drug treatment programs to distribute without a prescription.^[15] Funding for the drug and lack of knowledge, and use of, the standing order for obtaining naloxone without a prescription remain barriers to widespread access.^[16]

Police Procedure Post-Naloxone

Many police officers feel frustration and a sense of futility with naloxone administration due to:

• The cyclical and chronic nature of opioid use disorders.
• Repeated need for revivals of the same individuals.
• The prevalence of opioids in their communities.
• The lack of accessible local substance use disorder treatment.^[17]

Despite these concerns, most officers view overdose prevention and response as key components of community policing and positive police-community relations.^[18]

It is incumbent upon first responders to look beyond the immediate resuscitative value of naloxone.^[19] A review of emergency medical services data from Massachusetts found that of 12,000 dosages of naloxone administered between 2013 and 2015, 35 percent were dead a year from an opioid overdose.^[20] Therefore, each police department should establish procedures for the administration of naloxone and immediate follow-up. Immediately following administration, officers should encourage transportation to the local emergency department. Those who are able to make their own medical decisions, may choose not to access follow-up care.^[21] The World Health Organization views post-resuscitation as a “teachable moment,” in which individuals may be vulnerable and open to discussions on treatment options. ^[22]

Additional, appropriate, post-naloxone responses for police and other first responders include:

• Providing clear information on how naloxone works and its potential side effects, as well as addressing withdrawal symptoms.
• Offering sensitivity to individuals’ likely and understandable fears and concerns.
• Providing and instructing on the use of take-home naloxone to administer to others.
• Providing information on relevant laws, such as drug paraphernalia laws and non-arrest according to Good Samaritan Law.
• Building and sustaining trust with the individual and their family members,
• Providing information on harm reduction strategies, including needle exchange programs.
• Sharing opioid use treatment options, referrals, and placement, as well as present or future assistance in accessing appropriate treatment when and if the individual is ready.^[23]

These responses have not been, but will need to be, thoroughly researched to determine which approaches are most effective.

Those with opioid use disorders are highly likely to experience or witness overdose events and can be provided with take-home naloxone to save lives. In a pilot program in San Francisco, Calif., 1,942 individuals were prescribed naloxone and trained on its use. Eleven percent reported using the provided naloxone during an overdose event, successfully reversing 355 overdoses.^[24]

Naloxone Plus: A Front-End Diversion Community Overdose Response Framework

The Center for Health and Justice at TASC developed the Naloxone Plus framework. The “Plus” refers to post-naloxone activities to rapidly connect the person with treatment and get them into recovery.^[25] Front-end diversion, also referred to as pre-arrest diversion or deflection, involves police engagement to help individuals without fear of arrest.^[26] The framework outlines post-overdose engagement by teams which include police, other first responders, behavioral health providers, and community members. Following the administration of naloxone, the teams engage the individual with treatment providers, recovery coaches, individuals, and their families and offer a “warm-handoff” to treatment. A warm-handoff features a professional offering a face-to-face introduction of the client to the treatment provider to which he or she is being referred.

The Naloxone Plus framework includes the following recommended strategies and practices that law enforcement and other first responders can use to increase success beyond administering naloxone:

• Access to naloxone by police, fire, emergency management services(EMS), community businesses, and community members.
• Use of data to rapidly identify individuals who have overdosed, and as part of a prevention approach, use predictive analytics to identify people and community areas at high risk of overdose (i.e., 9-1-1 calls for service) to offer a targeted response and direct resources.
• Immediate contact post-overdose with the individual offer assistance and to begin to establish a relationship.^[27]
• Rapid engagement of individuals in-person with daily follow-up to offer assistance and to engage in treatment when ready.
• Immediate access to treatment when the individual is ready. If treatment is not immediately available, four bridging activities can be used in the interim: 1) recovery coaches, 2) temporary housing for 2-3 weeks until the person can enter treatment, 3) social services, and 4) medication-assisted treatment, as clinically indicated and agreed upon by the person.
• Screenings and clinical assessments administered to secure a diagnosis and individualize treatment.
• Availability of all medication-assisted treatments for individuals who need them based on a clinical decision.
• Availability of recovery support services after treatment including, if not already part of the initiative, recovery coaches.
• Distribution of naloxone to individuals, their friends, and family. Those with opioid use disorders are highly likely to experience or witness overdose events and can be provided with take-home naloxone to save lives.^[28]

Multi-Disciplinary Team Response Post-Naloxone

Multidisciplinary teams (MDTs) feature a group of representatives from three or more disciplines who work collaboratively toward a shared goal and shared definition of the problem they are addressing.^[29] MDTs can be used to tackle many criminal justice problems, such as elder abuse, domestic violence, and homicide, as well as issues in many other areas. No research is available on the use of MDTs to address opioid overdose, but other MDT models have been rated as promising or evidence-based.^[30] Overdose response teams and overdose fatality review teams follow a multi-disciplinary team approach.

Overdose Response Teams

Overdose response teams reach out to individuals post-naloxone and offer assistance as outlined in the Naloxone Plus framework. The goals of the teams are to:

• Enhance public safety response to life saving needs of the community.
• Increase education and support to the community on addiction.
• Help overdose victims access treatment.
• Reduce deaths and repeat incidences of overdose.
• Actively engage victims and family while building relationships and trust.
• Reduce drug flow and trafficking through increased intelligence gathering.^[31]

The figure offers a program spotlight on an Ohio overdose response team started in 2015. In 2014, a similar initiative, the Drug Addiction Resource Team (DART) began in Lucas County (Toledo). Similar teams have been established in New Mexico and Massachusetts. In addition, states such as Connecticut have used mobile response units and recovery coaches to offer support post-resuscitation. To date, Illinois does not have an overdose response team.

PROGRAM SPOTLIGHT: Quick Response Team, Colerain Township, Ohio

Colerain Township, Ohio, near Cincinnati, is approximately 46 square miles with 56,000 residents. Opioids, predominantly heroin, and subsequent overdoses hit the area in 2009. First responders were reversing overdoses on the same people multiple times but were left shrugging their shoulders about how to help post-naloxone. Colerain Public Safety Director Daniel Meloy employed a problem-oriented operating philosophy to create a proactive response model to the opioid crisis. The police, fire, and paramedics started simply by creating a packet with information about addiction, harm reduction, and treatment options to offer following an overdose. The packets were distributed to every person who experienced an overdose and those who were thought to be in need of treatment.

A quick response team also was formed consisting of police and fire personnel, mental health and substance use treatment providers, and peers in recovery. The teams review overdose-related police reports and began visiting homes of individuals who experienced an overdose and were assisted by police. They explain to the individuals, their friends, and families that they were there to offer help versus making an arrest or for any other punitive reason. The team offers naloxone kits, assistance with creating an overdose prevention plan, guidance in signing up for medical insurance, and support in accessing treatment. They will arrange for treatment and provide transportation upon the individual’s request. Between July 2015 and March 2107, the team followed up on 305 overdoses, conducted 250 face-to-face meetings, and helped 205 individuals enter treatment. The team operates four days a week with hopes of expansion to seven days.

Source: D. Meloy, personal communication, September 26, 2017 Note: For more information on QRT contact Daniel P. Meloy, CLEE, Colerain Township Administrator and Director of Public Safety at (513) 923-5015 or dmeloy@colerain.org

Overdose Fatality Review Teams

Police departments might consider creating overdose fatality review teams. These teams are modeled after child fatality review teams in which police, medical professionals, public health representatives, members of child protective services, and medical examiners review cases and make recommendations.^[32] In 2014, Maryland established three local overdose fatality review teams (LORFTs). A case study of one LORFT supported the following recommendations:

• Improve access to treatment information for family and friends of drug users.
• Increase public education about the dangers of alcohol use alone and in combination with other substances of abuse.
• Enhance outpatient care coordination and patient navigation of the care continuum after inpatient programs for substance use.
• Develop stronger collaboration with primary care providers.
• Build a greater partnership with the Department of Veterans Affairs.^[33]

Similar to overdose response teams, these teams feature community members seeking ways to successfully respond to overdose and improve outcomes for individuals post-naloxone.

Emergency Department Engagement Post-Naloxone

In addition to first responders, emergency departments (EDs) are a good post-naloxone intervention point. Because naloxone brings on immediate withdrawal, it offers the opportunity for intervention with a partial opioid agonist, buprenorphine.^[34] Buprenorphine (also known as Suboxone®) is an effective partial agonist, partially activating opioid receptors in the brain, with a ceiling effect meaning effects do not increase after that point, even with increases in dosage. Buprenorphine is a safer medication than other opioid medication therapy, such as methadone, in terms of the risk of respiratory depression and death.^[35]

One study used a random control trial of 329 opioid-dependent patients in an ED at an urban teaching hospital to examine the outcomes of three interventions:

1. Screening and referral to treatment.
2. Screening, brief intervention, and referral to treatment.
3. Screening, brief intervention, ED-initiated treatment with buprenorphine, and referral to primary care for 10-week follow-up.

The study found that after one month, 37 percent in the referral group, 45 percent in the brief intervention group, and 78 percent of individuals in the buprenorphine group were engaged in treatment on day 30. The buprenorphine group had the greatest success with engagement in treatment, reduced self-reported illicit opioid use, and decreased use of inpatient services.^[36] A replicated study in New Haven, Conn., revealed similar results.^[37]

Conclusion

The opioid crisis devastating communities has prompted health and justice practitioners to seek and implement innovative and effective approaches to managing substance use disorder and threat of overdose. A crisis of this magnitude requires use of promising and evidence-based strategies at multiple intervention points as part of a comprehensive plan to aid in the treatment of and recovery from opioid use disorders. Engagement post-naloxone administration can be used as one of many approaches to reduce the impact of the opioid crisis. The Naloxone Plus framework serves as a guide to engaging residents after overdose and revival through use of naloxone. Multidisciplinary police efforts involving fire department personnel, paramedics, public health and substance use treatment providers, recovery coaches, support groups, volunteers, and the faith-based community serve as another pathway for individuals in need of substance use disorder treatment.