Drug Overdose Prevention Tackle Box - A Guide for Communities
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Drug Overdose Prevention
Tackle Box
A Guide for Communities
Photo courtesy of NeONBRAND/Unsplash
Suggested citation: McCool R, McKee S, Clatos R, Quesinberry D, Bunn T. Drug Overdose Prevention Tackle Box: A Guide for Commu- nities. Lexington, KY: Kentucky Injury Prevention and Research Center; 2020. The Kentucky Injury Prevention and Research Center (KIPRC) is a partnership between the Kentucky Depart- ment for Public Health and the University of Kentucky’s College of Public Health that combines academic investigation with practical public health initiatives. This publication was supported by the Grant or Cooperative Agreement Number, NU17CE924971-02-01, funded by the Centers for Disease Control and Prevention. Its contents are solely the responsibility of the authors and do not necessarily represent the official views of the Centers for Disease Control and Prevention or the Department of Health and Human Services.
Drug Overdose Prevention Tackle Box User Evaluation Survey
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Part I – Program Selection, Implementation, and Evaluation
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Part II – Program Directory
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CONTENTS
PART I
Introduction: What Is the Drug Overdose Prevention Tackle Box?.................................... 1
Chapter 1: Complexities of the Current Drug Overdose Epidemic................................... 3
Understanding and Talking About Substance Use as a Disease................................ 5
Prevention, Harm Reduction, Treatment, and Recovery ........................................... 7
Setting Matters: Urban Versus Rural Communities ..................................................... 11
Weaving a Net ............................................................................................................... 11
Program Categories: What Do the Terms Mean? ..................................................... 15
Chapter 2: Selecting, Implementing, And Evaluating Programs..................................... 17
Considerations for Program Selection ........................................................................ 17
Implementing Programs ............................................................................................... 18
Evaluating Programs ..................................................................................................... 19
Data Sources................................................................................................................... 21
Additional Resources .................................................................................................... 22
Notes .................................................................................................................................... 25
Glossary................................................................................................................................. 27
PART II
Introduction: Program Category Definitions...................................................................... 39
Program Descriptions............................................................................................................ 41
INTRODUCTION
WHAT IS THE DRUG OVERDOSE PREVENTION TACKLE BOX?
T
he individual and social impacts of This complex problem requires a
the drug overdose epidemic have left multifaceted approach, especially at the
many communities searching for ef- community level. Multiple strategies and
fective ways to reduce substance misuse and programs are required to target varying
drug overdoses. The complex nature of the age groups—from teens and young adults
problem will require widely accepted and through working-aged adults to seniors—
evaluated intervention strategies for com- and individuals with widely varying educa-
munity leaders, public health officials, and tion and income levels.
health care providers. This tackle box has a specific func-
Local, state, and federal agencies and tion: to help catch fish. While most of the
nongovernmental organizations have re- items in a tackle box are designed to encour-
sponded to the lack of effective intervention age fish to take the bait or lure offered to
strategies by producing toolkits that provide them, the information in this tackle box is
background information, an understanding designed to help Kentucky’s communities
of how to select and implement interven- encourage individuals to avoid inappro-
tion projects or strategies, and recommen- priate or illicit substance use if they are not
dations for potential prevention strategies. already using substances and to seek treat-
Some toolkits are undoubtedly better or ment if they are already a substance user.
more comprehensive than others, but most As the drug overdose epidemic is
toolkits provide useful information and everchanging, we’ve designed this tackle
guidance. In many ways, this document is a box to expand as we discover promising and
toolkit like any other. However, we prefer, proven programs. We hope that commu-
based on the philosophy behind our work, nities will reach out to us about programs
to think of this document as a tackle box. not already included in this publication that
Tools are used to fix broken things they are interested in implementing or have
and problems and to adjust things that already launched.
aren’t working properly. This may lead to
an outdated and ultimately less useful view
both of people who use substances and of
communities with high rates of substance
use. It is all too easy to think of individuals
with substance use disorder (SUD) and com-
munities with high rates of substance misuse
as “broken” and to believe that if we can just
find the proper tool for the job we can “fix”
them.
1
CHAPTER 1
COMPLEXITIES OF THE CURRENT
DRUG OVERDOSE EPIDEMIC
M
any Kentuckians first became effective than other opioids, a massive mar-
aware of substance use disorder keting campaign that included a systematic
as a serious problem when opioid effort to minimize the drug’s perceived risk
overdose rates began to climb significantly of addiction led to widespread use of the
in rural Kentucky in the early 2000s. The is- medication. Prescriptions for OxyContin
sue, however, is not a recent one. High rates skyrocketed from 316,000 nationwide in
of substance use and SUD were present, 1996 to more than 14 million in 2002.4 SUD
especially in the Appalachian region, much rates likewise soared, and the issue reached
earlier. national media prominence in 2001.5
As early as 1971, physicians in rural The Kentucky All-Schedule Prescrip-
Kentucky noted high rates of substance use tion Electronic Reporting (KASPER) system
among their patients.1 In many cases, the was developed in 1999 primarily to address
drugs involved were “nerve pills”—benzo- the rapid increase in SUD cases associated
diazepines such as Valium and Xanax—that with high rates of opioid prescribing and
relieve anxiety and produce a calming ef- diversion in the state. Congress authorized
fect.2 These medications can also relax tight funding for Operation UNITE, a program
muscles and produce a comfortable, drowsy aimed at reducing unlawful narcotic use
feeling in the user. It isn’t surprising that through enforcement, treatment, and pre-
they became very popular, especially among vention education. Operation UNITE was
individuals who worked in physically de- limited to 32 counties in eastern and south-
manding jobs. eastern Kentucky, regions where illicit sub-
Somewhat later, hydrocodone, a stance use was higher than the state average.
powerful opioid analgesic (pain reliever), The late 1990s and early 2000s saw
began to be widely prescribed in Kentucky. methamphetamine use become much more
Like the benzodiazepines, it rapidly became prevalent, especially in rural portions of the
popular. Rising rates of hydrocodone pre- state.6 The widespread adoption of less com-
scribing led to concerns about the addictive plex and hazardous production (“cooking”)
potential of the drug.3 techniques made the drug readily available,
Concerns about diversion and mis- since it could be manufactured from easily
use of hydrocodone created a ready-made accessed precursors. Methamphetamine
market for a medication that could provide garnered the majority of public and political
similar effects without the strong potential attention related to substance misuse during
for abuse. In 1996, Purdue Pharma began the early 2000s; opioid use received less
marketing OxyContin as a less easily mis- concern. The federal Combat Methamphet-
used alternative to other opioid analgesics. amine Epidemic Act (2005) and similar state
While US Food and Drug Administration laws reduced access to precursor chemicals,
studies indicated that the drug was no more while other legislation (e.g., KRS 218A.1437,
3
enacted in 2002) added criminal penalties for years from 2015 to 2017.8
possession of precursors. These efforts reduced Data from 2018 and 2019 indicate a
the accessibility of methamphetamine, but it reduction in overdose-related fatalities, but
remained a commonly used drug, especially in detailed data from these years are not yet avail-
rural communities. able for analysis. This makes it impossible to
In 2012, the Kentucky legislature passed determine whether the decline in fatalities is due
HB 1, which imposed significant new restric- to a reduction in overdose incidents or to in-
tions on pain clinics, promoted the develop- creased success in preventing fatalities through
ment of regulations for prescribing opioids, overdose reversal with naloxone and improved
and required the use of KASPER by prescribers. post-overdose care.9
The law reduced “doctor shopping” by more Perhaps the most concerning trend is
than 50%, resulted in the closure of numerous the resurgence of methamphetamine use. Rural
pain clinics, and imposed a mandate that more law enforcement agencies, the Kentucky State
than tripled the number of prescribers who Police, and health care providers are all report-
are required to access KASPER to review pa- ing significant increases in methamphetamine
tients’ prior prescriptions before prescribing use.10 This trend is confirmed by public health
opioids.7 These changes, along with increased data, which show a 35% increase in metham-
law enforcement focus on medication diversion phetamine-related overdose fatalities between
and illegal prescribing practices, substantially the first quarter of 2017 and the first quarter of
reduced illicit access to prescription opioids. 2018.11 Unlike previous years, when most meth-
Unfortunately, the reduction in the sup- amphetamine used in the Commonwealth was
ply of prescription opioids did little to reduce “cooked” locally, large amounts of the drug are
either the number of individuals suffering from now being illegally imported from sources out-
SUD or the overall availability of opioids. In side the United States. The volume of illegally
urban areas, the relatively widespread avail- imported methamphetamine has made the drug
ability of heroin at comparatively low prices led readily available and comparatively cheap.
many individuals to transition from prescription The resurgence in methamphetamine
opioids to heroin. While prescription opioid use is particularly concerning because there is
overdose deaths peaked in 2011 and then be- no readily available, effective medical treatment
gan a modest decline, heroin-related overdose to reverse the effects of a methamphetamine
deaths—negligible prior to 2008—increased overdose. Naloxone, which is highly effective
rapidly.8 During this period, programs such as at reversing the effects of opioid overdose,
naloxone distribution and syringe exchanges has no effect on methamphetamine overdose.
began to be utilized to reduce the harm caused Additionally, individuals who are experiencing
by substance use disorder. symptoms of methamphetamine overdose are
Beginning around 2015, an alarming new often more active and potentially aggressive
trend became evident. Fatal heroin overdose than those who are experiencing an opioid over-
rates leveled off and even declined slightly, dose. These factors are requiring public safety
but fatal overdoses due to the use of synthetic agencies, health care providers, and others to
opioids, primarily fentanyl, and the number reevaluate and adapt their overdose response
of overall fatal overdoses grew. By 2017, this protocols.
growth had become explosive, with synthetic Kentucky has experienced high rates
opioid overdoses more than doubling in the two of substance misuse, and related overdose
4 Drug Overdose Prevention Tackle Boxincidents, for decades. The mass marketing of Over the past few years, we have
prescription opioids in Appalachia in the late reached a new level of understanding about
1990s certainly exacerbated the situation, but how various substances change human behavior
that marketing campaign focused on the re- and even our brain chemistry. This understand-
gion in large part because of the already high ing has changed how we view, and respond to,
rates of opioid and benzodiazepine prescribing substance use. Specifically, we now know that
there. A variety of economic, social, cultural, regular substance misuse over a period of time
and individual factors are involved in the high leads to changes in brain chemistry, thought
rates of substance use and SUD in the Common- patterns, and behaviors. Once those changes
wealth. To understand our current epidemic of have occurred, they are difficult to reverse and
substance misuse and SUD, it is important to attempts to do so often lead to physical illness
recognize that the issue goes beyond any single and substantial discomfort.
substance. As one treatment provider noted, These factors help to explain why tra-
“It isn’t a drug problem; it’s an addiction prob- ditional treatments often have low long-term
lem.” To effectively address this complex and success rates. Individuals with substance use
longstanding issue, we will need to embrace disorder don’t necessarily have low willpower,
efforts that do more than focus on a single area weak moral standards, or a lack of understand-
of the issue or a single substance. We will need ing of the harm caused by their substance use.
to focus not only on individuals suffering from Instead, they have an altered brain chemistry
SUD but also on environmental, community, that creates a strong physiological and psycho-
and systemic factors that impact substance use logical need for the substance. They aren’t using
and the risk of overdose. the substance to get high; they are using it to
avoid becoming (and feeling) very ill.
UNDERSTANDING AND TALKING ABOUT Our growing understanding of the
SUBSTANCE USE AS A DISEASE biochemical processes involved in problematic
substance use has also led to a change in the
Historically, individuals who misused
terminology that we employ. In the past, the
substances such as alcohol or illicit drugs were
term “addiction” was typically used to describe
often viewed as having a moral weakness or
a situation in which a person was physiologi-
suffering from a lack of willpower. Treatment
cally or psychologically unable to stop consum-
regimens for individuals with problematic sub-
ing a chemical, drug, or substance, even when
stance use tended to focus on a detoxification
that chemical, drug, or substance was causing
process, where the individual suffered through
physical and/or psychological harm. The term
the physical withdrawal symptoms associated
“addict” was often used to describe a person
with the substance they used, followed by a
who was suffering from addiction. “Addiction”
long-term period of individual and/or group
is technically a value-neutral term, but it has
counseling. Treatment plans varied in their
acquired a great deal of secondary meaning in
details, but most depended upon educating the
common use; saying that someone is suffering
substance user about the harm that his or her
from addiction often leads others to think of
substance use was creating for him/herself and
a variety of images and stereotypical charac-
others and then helping the person to develop
teristics, most of which are negative. The term
and follow a plan for avoiding substance use
“addict” has become even more loaded with
through strength of will and changed personal
secondary meanings and is almost universally
habits.
Drug Overdose Prevention Tackle Box 5perceived as a negative label. used to mitigate the effects of opioid withdraw-
Using these terms can lead to stigmatiz- al. Eliminating the painful, debilitating illness
ing individuals who are chronic substance users. associated with opioid withdrawal can make it
While there is no evidence that concern about much easier for individuals suffering from opi-
social stigma leads any significant number of oid use disorder to stop or significantly reduce
individuals to avoid initial substance use, stud- their substance use.
ies have found that stigma can and does reduce Some people and organizations have
access to treatment and create other barriers to expressed concerns about viewing substance use
recovery for individuals with SUD. In partic- disorder as a disease and/or about using med-
ular, referring to a person as an addict defines ication to treat SUD. Some are concerned that
that person by his or her disease without recog- treating SUD as a disease minimizes the impor-
nition of the other aspects of his or her identity. tance of personal choice and absolves substance
The issues created by stigmatization have led to users of any responsibility for poor choices that
a preference for new, more descriptive, and less may have led to their substance use.
value-laden terminology. We can and must educate individuals
The term “substance use” refers to the and encourage them to avoid making choices
intentional consumption of drugs or alcohol and that may lead them to develop SUD. At the same
includes substances such as cigarettes, illicit or time, we must acknowledge that SUD is not the
“street” drugs, prescription drugs, inhalants, only disease that can result from poor choices.
and other chemicals that produce a physiologi- Many other illnesses, including heart disease,
cal or psychological effect. When a person’s use stroke, adult-onset diabetes, and hypertension
of one or more substances leads to health issues are strongly linked to personal choices that
or problems at work, school, or home, that per- individuals make about their health, nutrition,
son is said to have “substance use disorder,” or and level of exercise, yet we recognize that those
SUD. The term “substance abuse” is sometimes conditions are illnesses that are appropriately
used interchangeably with “substance use disor- treated with medical care. The same is true for
der,” but the latter term is typically preferred by SUD. Stigmatizing those who suffer from SUD
treatment and prevention specialists. When re- will not cause them to stop using substances; it
ferring to someone whose use of a substance has will simply reduce their chance of recovery.
become problematic, it is appropriate to refer to Concerns about the use of medication to
them as a person with substance use disorder treat SUD generally hinge on the idea that med-
rather than as an addict or drug user. ication therapy is simply trading one substance
Our growing understanding of the for another and/or that individuals suffering
biochemical aspects of SUD has also changed from SUD often require extended periods of
our understanding of substance use treatment. medication therapy. SUD is a complex, chronic
While earlier treatment plans often focused on disease, and we do not have a treatment that
detoxification followed by education and behav- offers a rapid, simple recovery. Type 2 diabetes,
ioral therapy, medication to treat substance use which results from a physiological deficiency
disorder is becoming increasingly utilized. This in the patient’s body, is a chronic, sometimes
is especially true in opioid treatment programs, incurable illness that can require lifelong insulin
where medications such as methadone and use. With regular insulin use, however, a pa-
buprenorphine (Suboxone)—either alone or in tient suffering from diabetes may lead a full and
combination with behavioral therapy—can be productive life. The same is true for individuals
6 Drug Overdose Prevention Tackle Boxsuffering from SUD; they may require long-term educating individuals about the risks of sub-
medication therapy, but that therapy may en- stance use, reducing risk factors for substance
able them to lead a healthy and productive life. use, and increasing protective factors.
Finally, it is important to realize that a Risk factors are characteristics within an
drug overdose is not the same as substance use individual or conditions within a family, school,
or SUD. SUD is best characterized as a complex, or community that increase the likelihood that
chronic disease with both physiological and the individual will engage in substance use.
psychological components, while drug overdose Risk factors for substance use include living in
is categorized as an injury. Like any other poi- poverty or facing financial insecurity, living in a
soning, an overdose is an acute condition that household where others use substances, child-
occurs when a substance that can cause injury hood trauma, drug availability in the communi-
or death is taken into the body. Thus, substance ty, substance use by friends and peers, untreated
use and SUD prevention can be seen as over- mental illness, social isolation, and others.
dose prevention, but not all overdose preven- Protective factors are characteristics
tion strategies are designed to prevent or reduce within an individual or within a family, school,
substance use. or community that help the individual cope
The following article provides addi- successfully with challenges and stressors in
tional information about the importance of the his or her life. When people can successfully
language used to describe substance misuse resolve their problems and manage pre-exist-
and recovery: Substance use, recovery, and ing risk factors, they are less likely to engage in
linguistics: The impact of word choice on ex- substance misuse. Protective factors for sub-
plicit and implicit bias (www.ncbi.nlm.nih.gov/ stance use include strong, positive bonds with
pubmed/29913324). family members and friends, living in a stable
and supportive home, having basic living needs
PREVENTION, HARM REDUCTION, TREAT- met, economic security, not having experienced
MENT, AND RECOVERY physical or psychological trauma, academic
competency (for children and youth), faith or
There are multiple ways to reduce the
spirituality, and others. Primary prevention also
individual and social impact of the substance
includes strategies and programs designed to
use epidemic, but none of these approaches
reduce inappropriate prescribing and dispens-
provides a comprehensive answer for substance
ing of potentially addictive substances and the
use and SUD. These issues involve a complex in-
availability of illicit drugs. Primary prevention
teraction between individual and social factors.
is appropriate for individuals and populations
Specific strategies and programs can address
with little or no existing substance use.
aspects of the issue, but there is no single strat-
Harm reduction aims to reduce the
egy or prevention program that addresses the
harms, such as overdose and the potential
entire issue effectively. Just as a fishnet is wo-
transmission of diseases, associated with sub-
ven from many strands, effective interventions
stance use. When applied to substance use,
must be composed of numerous components
harm reduction accepts that a continuing level
that address a wide variety of factors related to
of substance use (both licit and illicit) in society
substance use and SUD.
is present, focuses on reducing the adverse con-
Primary prevention focuses on reducing
sequences that can result from substance use,
the number of individuals who choose to begin
and is aimed at reducing negative consequences
using substances. Prevention programs focus on
Drug Overdose Prevention Tackle Box 7associated with drug use. Harm reduction strat- previous living situation would expose him or
egies are appropriate for individuals who have her to an unhealthy environment. Recovery may
already developed SUD and who have not yet also include processes such as job training and
begun treatment and can be an important bridge employment assistance, continuing counseling
linking people to treatment and supporting their or participation in peer support groups, continu-
recovery efforts. ing healthcare, housing assistance, and other
Treatment involves efforts to help indi- services designed to minimize risk factors for
viduals reduce or eliminate their substance use. substance use and to help the person develop
There are many types of protective factors such as
treatment for SUD. Most coping skills and financial
start with detoxification, To link individuals with SUD to stability.
which often includes treatment facilities with avail- It is often helpful to
medically managed with- able openings, visit www. look at a complex situation
drawal. The illness asso- by using a model or dia-
FindHelpNowKY.org. For more
ciated with withdrawal is gram to help us consider
information on FindHelp-
accompanied by unpleas- ways to deal with it ef-
NowKY.org, see page 70.
ant symptoms and can be fectively. One of the most
fatal in some cases, so it is widely used models for in-
common to manage the pa- jury prevention is the Had-
tient’s symptoms through the use of medication don Matrix. Developed by William Haddon in
during the detoxification process. 1970, the matrix is a diagram of the relationships
Once the withdrawal process is com- between the host (human), agent (pathogen or
plete, the treatment program may include substance), and environmental factors involved
individual and/or group counseling, behavioral in an injury. By understanding the attributes of
therapy, medication therapy, psychiatric care, each of these factors at various stages in the inju-
or other types of treatment, either singly or in ry process, we can identify areas where we can
some combination. Treatment may be provid- intervene to prevent the injury, reduce its sever-
ed in a short- or long-term inpatient facility or ity, or at least mitigate the harm caused by the
through an out-patient program or provider. injury. The matrix on page 10 illustrates some
For more information about types of treatment factors and prevention opportunities associated
for SUD, we recommend reading Principles of with substance use and drug overdose.
Drug Addiction Treatment: A Research-Based In addition to developing the matrix,
Guide (Third Edition) by the National Institute Haddon developed 10 potential strategies for
on Drug Abuse. preventing or mitigating an injury that can be
Recovery, in the context of SUD treat- applied to prevent drug overdose, as outlined
ment, generally refers to an ongoing process below. Becoming familiar with them can help
that begins once initial treatment ends. Recovery you to evaluate potential programs and spe-
focuses on helping the patient manage his or her cific strategies that may help your community
disorder on a long-term basis. Recovery often to determine how a given program may affect
includes processes such as reestablishing rela- substance use and overdose risk.
tionships with family members and friends or to Pre-Event
build new friendships and a new support sys- Prevent the existence of the substance.
tem in cases where going back to the person’s It is very difficult to prevent the existence of
8 Drug Overdose Prevention Tackle Boxdangerous substances, but some examples of able to more accurately predict the effects of the
this strategy include law enforcement efforts dose they are using. The goal is to reduce the
to stop the illegal cultivation of marijuana and potency of the substance to a somewhat safer
legislative efforts to restrict access to the precur- level.
sor chemicals required to manufacture metham- Control the pattern of release of the
phetamine. substance to minimize damage. This strategy is
Prevent the release of the substance. applicable mostly to secondary risk factors such
This strategy involves limiting access to danger- as the spread of communicable diseases among
ous substances. It is most commonly seen in law those who use substances. Strategies such as
enforcement programs that target drug traffick- needle exchange programs and health education
ing, but strategies that promote proper prescrib- can help control the self-administration of sub-
ing and dispensing of prescription drugs as well stances in ways that reduce the risk of contagion
as prescription drug take-back programs also fit and lessen the negative health consequences of
within this overall strategy. substance use.
Separate the substance from the indi- Control the interaction between the
vidual. Inpatient treatment programs, incar- substance and individual to minimize damage.
ceration facilities, and post-treatment recovery The most obvious example of this strategy in
housing all strive to provide drug-free facilities action is the prompt administration of naloxone
where individuals do not have access to danger- to an opioid overdose victim by bystanders or
ous substances. immediate responders. Naloxone mitigates the
Provide protection for the individual. effects of the opioid on the victim in a way that
This strategy includes a vast number of pro- greatly increases the victim’s chance of survival.
grammatic strategies that focus on educating in- Increase the resilience of the individu-
dividuals about risks associated with substance al. Programs that educate individuals about the
use, risk factors for overdose, and strategies for signs of opioid overdose, the need for an imme-
avoiding substance misuse and/or overdose. diate response, and the process for self-care or
It includes both primary prevention efforts care for others can reduce the likelihood of fatal
focused on preventing substance use as well as overdose by helping those who use substances
harm reduction efforts that attempt to minimize to prepare physically and mentally to effective-
the risk of overdose events for individuals with ly mitigate an overdose. Immediate bystander
active substance use or SUD. This strategy can methods of care, such as provision of rescue
also include medical interventions such as the breathing or cardiopulmonary resuscitation
use of naltrexone to reduce the chance of relapse (CPR) and the administration of naloxone for
and overdose. Overall, the goal is to reduce opioid overdose, can also be considered ways to
individual risk factors and promote protective increase the individual’s capacity to survive the
factors. overdose incident. But they depend upon other
Event individuals to be part of the solution.
Minimize the amount of substance Post-Event
present. In the case of overdose prevention, this Provide a rapid treatment response for
strategy is applicable to efforts to keep fentanyl, the individual. Rapid response by trained and
carfentanil, and other extremely powerful opi- equipped first responders—even by those who
oids from being mixed in with other illicit drugs normally lack a medical role (e.g., law enforce-
so that individuals who use those substances are ment and firefighters)—and by citizen respond-
Drug Overdose Prevention Tackle Box 9ers significantly increases the chances of surviv- more than just access to a treatment program or
al for an overdose victim. Even in non-opioid facility; they also incorporate active outreach to
overdoses, where naloxone is not effective, substance users, intake processes that minimize
rapid access to supportive care such as airway barriers (e.g., lack of transportation, costs, fear of
maintenance and CPR can prove lifesaving to an separation from family, fear of suffering with-
individual suffering an overdose. drawal symptoms, etc.), rehabilitation services
Provide treatment and rehabilitation such as job training and transitional recovery
for the individual. Treatment and rehabilitation housing, and support for reintegrating the re-
are key to successfully reducing the burden of covering individual into the community.
substance use and overdose events, both for The Program Directory in Part II of this
individuals who use substance and for the com- document contains a list of numerous programs
munity. Effective treatment programs include and intervention strategies for addressing
Factors and prevention opportunities associated with substance use and drug overdose.
Individual (Host) Substance (Agent) Environment
Pre-Event • prevention educa- • illicit drug access • poverty reduction
(Non-Use) tion reduction (law • reduction of environ-
• reduction of indi- enforcement) mental stressors (e.g.,
vidual risk factors • implementation of crime, homelessness or
(e.g., untreated proper prescribing poor-quality housing)
mental illness or practices • economic security
pain) • drug take-back pro-
grams
Pre-Event • naloxone distri- • targeted enforce- • availability of monitored
(Active Use) bution and use ment to reduce substance use locations
education fentanyl and ana- • mutually supportive
• safer use educa- logues in illicit drugs social relations among
tion • limitation of total substance users
morphine milli-
gram equivalent of
opioids prescribed
to an individual
patient
Event • encouragement • prompt bystander care
of substance dose (including the adminis-
titration tration of naloxone for
• education of warn- opioid overdose)
ing signs of immi-
nent overdose
Post-Event • rapid public safety
response to overdose
events
10 Drug Overdose Prevention Tackle Boxsubstance use and drug overdose in your com- ic isolation, high rates of poverty, a lack of (or
munity. Just as some fish prefer shiny spinners limited) access to health care and mental health
and others are most easily caught with live bait, services, increased availability of prescription
different individuals and populations will likely opioids in some communities, limited law en-
benefit from differing programs. The programs forcement (with concurrently fewer resources
we have listed, and others that are offered by for drug access reduction), a high percentage of
other sources, are the lures in your tackle box— the working population engaged in physically
the specialized tools that allow you to target the demanding occupations that increase the like-
specific needs of your community. Understand- lihood of acute or chronic pain, limited and/or
ing how prevention strategies work at a broad delayed access to naloxone, EMS, and hospital
level will help you to select and support effec- care for overdose patients, and limited access to
tive programs and intervention strategies. substance use prevention and treatment pro-
grams. Rural communities may also have some
SETTING MATTERS: URBAN VERSUS RURAL protective factors such as more limited access to
COMMUNITIES illicit drugs, stronger bonds between individuals
and their neighbors and community, and in-
Some people perceive that substance
creased access to outdoor activities in the natu-
misuse and overdose-related injuries and fatali-
ral environment.
ties are primarily an urban issue, but this is not
Studies have found that alcohol use,
the case. Many urban communities do have high
binge drinking, and methamphetamine use are
rates of substance misuse and overdose, but the
all higher in rural youth and young adults than
same is true for many rural communities. While
in their urban counterparts.12, 13 Opioid use is
the issues are similar in both types of communi-
high in many rural areas, and the five states
ties, some differences must be considered.
with the highest drug overdose fatality rates are
Urban communities face a number of
predominantly rural, though urban areas also
specific risk factors such as high rates of social
experience high rates of opioid use.14 Suburban
and income inequality, high poverty rates in
communities typically have a mix of urban and
specific sections of the community, easier and
suburban characteristics, but most tend more
more diverse access to illicit drugs, limited links
toward the urban profile.
between individuals and the broader commu-
Whether urban or rural, each community
nity, stressors associated with urban traffic and
is unique. It is important to consider your com-
congestion, pollution, and frequent environ-
munity’s setting and characteristics, resources,
mental changes. Urban communities also have
and unique cultural environment when select-
positive, protective factors such as greater access
ing substance use and drug overdose preven-
to health care and mental health services, nu-
tion strategies. Programs designed for specific
merous opportunities for participation in social
environments and resource levels may work
and athletic organizations, large law enforce-
less well, or not at all, in communities that are
ment agencies capable of supporting substantial
substantially different. A knowledgeable angler
drug access reduction efforts, and rapid access
with a well-stocked tackle box can select the
to initial responder naloxone administration,
most appropriate equipment for the situation.
emergency medical services (EMS), and hospital
We believe that the same is true for substance
care for overdose patients.
use and overdose prevention strategies.
Rural communities have some specific
risk factors of their own, including geograph-
Drug Overdose Prevention Tackle Box 11WEAVING A NET the business community, and everyone else who
has a stake in addressing the issues of substance
If you want to catch a few fish, a fishing
misuse and drug overdose in your community.
pole with a single line is the tool of choice. If you
Ideally, your coalition should include individ-
need more fish, you can fish with several lines.
uals who are using substances or who have
If you want to catch different types of fish, you
recently recovered from SUD. They best un-
will usually need to employ a different type of
derstand the needs and concerns of others with
lure on each line. To catch a large number of fish
SUD, and they are often the most effective link
of several different types, however, the best way
between those who want to help and those who
is to weave many lines together to make a net.
need help.
The same principle applies to prevent-
Building and maintaining an effective
ing substance use and drug overdose. A single
coalition can be more complicated than many
program can target a particular demographic
people expect. There are many books, classes,
group, but it is unlikely to be effective across a
and programs that provide guidance on coa-
wide spectrum of age cohorts, socio-economic
lition building. Training and advice are also
levels, and social groups. Most programs also
available from the Drug Overdose Technical As-
target a specific aspect of the substance use
sistance Core (DOTAC) at the Kentucky Injury
situation (for example, teaching youth to avoid
Prevention and Research Center. Providing de-
substance use altogether but not addressing
tailed guidance in coalition building is beyond
overdose prevention among those who are al-
the scope of this tackle box. We will, however,
ready using substances).
list the key activities of an effective prevention
Even in small communities, multiple
coalition.
programs are likely to be needed to address
multiple aspects of substance use and overdose Build a Functioning Coalition
risk in the community. Different programs and This process involves more than simply
approaches will be needed for different audi- inviting people to a meeting; it involves identi-
ences. Multiple independent programs can be fying key leaders and stakeholders in your com-
effective, but they will have a greater overall munity, determining how each might be able to
impact when they work together to address the contribute to the coalition’s efforts, and identi-
prevention needs of the community. By sharing fying the key decision-makers within potential
information and resources, and by helping to partner organizations. Coalition development
transition individuals smoothly between differ- includes the following steps:
ent programs as needed, the needs of different Secure support and involvement from
individuals at differing stages of the substance community leadership. This can include the
use continuum can be met. Providing com- chief executive of your local government or in-
prehensive programs that range from primary stitution, members of your city council or fiscal
prevention to harm reduction to treatment and court, and other elected officials (e.g., your sher-
rehabilitation offers individuals the best chance iff, coroner, jailer, constables, property valuation
to avoid substance use or to recover from SUD. administrator, etc.). Others to involve include
To build an effective net, you need a senior appointed officials (e.g., chiefs of public
network—a coalition of individuals and organi- safety agencies, your local or regional public
zations that are providing or supporting preven- health director, and others), key members of the
tion and treatment programs, local officials and business community, representatives of orga-
policymakers, concerned citizens, members of nizations involved in substance use prevention
12 Drug Overdose Prevention Tackle Boxand treatment (e.g., local Agency for Substance coalition’s role, responsibilities, and mission that
Abuse Policy boards, Regional Prevention may occur.
Centers, and private organizations), healthcare Focus on building positive working
providers, and others with a stake in preventing relationships. In too many communities, pre-
or reducing substance use and drug overdose vention efforts are hampered by competitive
events in your community. (rather than cooperative and collaborative) re-
Establish a core group. Bring together lationships, personal disagreements, and a lack
key stakeholders to outline the goals and scope of compromise. A net is only effective when it
of your coalition. What will you do, and what is strongly woven and doesn’t have large holes.
geographical area will you serve? Consider Prevention and treatment efforts are most effec-
leveraging an existing group, if one exists, when tive when they are collaborative, interconnected,
forming your coalition. This group may serve as and work cooperatively to meet community
an incubator for your coalition or even develop needs.
into the core group for your coalition. Your core Perform (or Update) a Community Assessment
group can help you develop a mission statement Before you begin planning new pro-
and initial plan, identify data sources (see page grams and intervention activities, you need
21) and potential resources, and encourage oth- to clearly determine what your community’s
ers to join. primary needs are and what programs are
Identify a lead organization. In most already addressing those needs. Your coalition
cases, it is best for one organization to take the should identify reliable sources for data about
leadership role in the coalition-building process. substance use and drug overdoses in your com-
We highly recommend two leads from different munity. Data may be formal (e.g., reports and
organizations. The lead role may change over statistics from government agencies and health
time, and the coalition can be led by any orga- care organizations) or informal (e.g., the first-
nization. The purpose for having lead organiza- hand experiences of local emergency responders
tions is to ensure coordination for meetings and and healthcare providers). Once you have data
provide a consistent point of contact for coalition available, your coalition should review it to de-
members. The lead organizations’ role is admin- termine what the most pressing needs are.
istrative, not managerial; important decisions Your coalition should also perform, or
should be made by the coalition as a whole. update, a community assessment to identify
Develop a guidance document to pro- existing programs that are already in operation
vide structure for your coalition. Whether as well as any laws and policies, processes, and
you call this document your bylaws, terms of practices that are in place to address the issue.
reference, a memorandum of understanding, When you identify existing programs, include
or something else really doesn’t matter. What information about the type of work done by
matters is that your coalition needs a written each program, the group(s) that it serves, and its
set of guidelines for how members are selected, capacity. Identify any existing partnerships and
how (and when) leaders will be chosen, when working groups and invite them to join or col-
meetings will be held and how they will be laborate with your coalition. Finally, include in
conducted, and how decisions will be made. The your assessment an inventory of resources and
guidance document will help ensure that your expertise available to your coalition. Knowing
coalition is more than just an informal discus- what you already have will help you to deter-
sion group and resolve any disputes about the mine what you still need.
Drug Overdose Prevention Tackle Box 13Perform a Gap Analysis other hand, working toward an unrealistic and
A gap analysis is simply a review of unattainable goal can soon sap the energy and
what programs and interventions are needed, motivation from your coalition members. The
and those that are available, to identify any ideal goal is one that requires effort but that can
gaps. For example, a community might have a also be achieved and will represent meaningful
school-based substance use prevention program progress.
for children and teens, a needle exchange harm Select, Implement, and Evaluate Intervention
reduction program for substance users, and Projects and Programs
treatment available for those who are ready to Once you have identified groups and
accept it, but the community lacks any prima- situations that need attention, you can select
ry prevention programs for adults or a rapid programs and intervention strategies that meet
response program for drug overdose events. By those needs. The Program Directory includ-
comparing existing programs and interventions ed in this tackle box offers a large number of
to the needs you have identified, your coalition options, and other program ideas are available
can identify groups that are not being adequate- from a wide variety of sources. Later sections
ly served and situations that are not being fully will provide information about how to select,
addressed. implement, and evaluate programs. The most
Set Goals and Programmatic Priorities important things to keep in mind are that you
In most cases, a coalition will not be should select programs that match your com-
able to immediately address all of the gaps that munity’s needs and available resources and that
have been identified. Even if community needs have evidence to support their effectiveness.
do not exceed the available resources, the time Once you have selected appropriate interven-
required to select or develop and implement tion programs, you should follow best practices
programs means that some will be implemented in implementing those programs and evaluate
before others. Your overall priorities should be them regularly to ensure that they are working
based on your community’s needs, as identified effectively. Additional information about pro-
during your analysis of substance use and over- gram implementation is provided in chapter 2.
dose data for your community. To address those When you select and implement strat-
priorities, however, your coalition will need to egies and programs, it is important to remem-
set specific goals and decide which intervention ber that they likely will change over time. The
programs should be developed first. substance misuse and drug overdose epidemic
It is important to keep your goals specific is a result of many complex and interconnected
and measurable. A goal to reduce the problem social and cultural factors that will likely persist
of drug overdoses in your community isn’t for decades, if not longer. This does not mean
really measurable, but a goal of reducing the that we cannot make progress against the epi-
number of drug overdose patients who require demic; it only means that progress will some-
an emergency medical services response by 50% times be slow and that it may take a generation
within three years is measurable. You should or more to return substance use and overdose
also choose goals that are attainable but that are rates to their pre-epidemic levels.
not too easy to accomplish. Accomplishing easy Additionally, the demographic groups
goals may feel good, but it is unlikely to make with higher rates of substance use and greater
a significant impact on substance use and drug overdose risk will change over time and inter-
overdose events in your community. On the vention strategies and specific programs will
14 Drug Overdose Prevention Tackle Boxneed to evolve to reflect these changes in the Promising strategies are based on logical
‘at-risk’ population. design and available evidence but may address
Just as with fishing, patience is a key areas of practice where the available evidence
quality for those working to reduce substance is limited or even nonexistent. This may be the
use and drug overdoses. case because they address a new area of practice
where little research has been done or because
PROGRAM CATEGORIES: WHAT DO THE they address complex issues where the existing
TERMS MEAN? research is inconsistent or ongoing. A lack of
available evidence for a strategy does not mean
It is important to choose substance use
that the strategy does not work; it may simply
prevention and overdose prevention strategies
mean that the strategy has not yet been properly
that have the best available evidence to support
evaluated. If you choose a promising practice,
them. Even the least complex strategies and
carefully evaluate the strategy throughout
prevention projects require a substantial invest-
the implementation process to ensure that it
ment of time, money, and other resources to
achieves the planned objectives.
implement. Choosing strategies that have been
Unsupported strategies are those that
evaluated and found to be effective is the best
have been evaluated and did not show evidence
way to ensure that limited resources are used as
of being effective. In some cases, the failure to
efficiently as possible. When selecting interven-
find evidence of effectiveness may have been
tion strategies, it is important to understand the
due to a poor research design or because the
various levels of evidence of effectiveness.
study sample size was too small. Unsupported
Evidence-based strategies, practices, and
programs may be worthy of additional research
programs are those that have been evaluated in
and evaluation, but we cannot recommend an
a formal, rigorous way, using a strong research
unsupported strategy for use in a community
design, and found to be effective at achieving
setting.
the goals for which they were designed.
Harmful strategies are those that have
You may sometimes see evidence-based
been evaluated and evidence was found that the
strategies described as “supported” or
program may actually have a negative effect.
“well-supported.” These terms refer to the
For example, a youth tobacco-use prevention
strength of the research design used to evaluate
program might have been found to increase the
the strategy. In general, the evidence that deter-
use of tobacco among teens who participated
mined the efficacy of a “well-supported” strat-
in the program. We strongly recommend that
egy is likely to be somewhat stronger than the
you do not implement strategies that have been
evidence for a “supported” strategy, but both
found to be potentially harmful.
have been evaluated and found to be effective.
Additional information about the lev-
Evidence-informed strategies, practices,
els of effectiveness can be found in A Guide to
and programs use the best available research
the Continuum of Evidence of Effectiveness. This
and practice knowledge to guide program
document, published by the National Center for
design and implementation, but they have not
Injury Prevention and Control, can be found on-
been evaluated sufficiently to be described
line at www.cdc.gov/violenceprevention/pdf/
as evidence-based. While they have not been
understanding_evidence-a.pdf.
fully evaluated, evidence-informed strategies
Understanding the evidence level avail-
are typically the best choice whenever an evi-
able to support a particular strategy can help
dence-based strategy is not available.
Drug Overdose Prevention Tackle Box 15you select the best programs to prevent sub- In situations where there is no evidence-based stance use and drug overdoses in your commu- program that addresses your specific needs, the nity. When an evidence-based practice is avail- selection of evidence-informed or promising able, we strongly recommend that it be selected. practices should be the next choice. 16 Drug Overdose Prevention Tackle Box
CHAPTER 2
SELECTING, IMPLEMENTING, AND
EVALUATING PROGRAMS
CONSIDERATIONS FOR PROGRAM totally ineffective for teens. It might even be
SELECTION harmful, if the teens feel that they are being
I
treated like young children. Additionally,
n the best of all worlds, your gap analysis
choose programs that were designed for the
would reveal that there are no significant
purpose (e.g., primary prevention versus
holes in the substance use prevention
harm reduction) that you need to address.
and harm reduction/overdose prevention
Select programs that your local
programs in your community. Should that
resources can support. Even the most effec-
be the case, your coalition will need only
tive program may fail if it cannot be imple-
to facilitate coordination and cooperation
mented correctly. Some programs require
between the existing programs. Most coa-
extensive (and expensive) resources, such
litions, however, will identify a number of
as facilities, specially trained staff, medica-
gaps in the prevention and harm reduction
tions, etc. Others can be implemented with a
services available in their community. When
much lower investment. SUD is a long-term,
gaps are found, the next step is to identify
chronic condition, so it is important to look
and select appropriate intervention pro-
at the cost and effort required to maintain
grams to fill the gaps.
your prevention and harm reduction pro-
There are a variety of issues to
grams over the long term. Selecting the most
consider when selecting specific interven-
effective programs that you can support is
tion strategies and programs to implement
a wise choice, but it is important to avoid
in your community. We have already dis-
selecting programs that you are unlikely to
cussed the need to focus on evidence-based
be able to implement and sustain.
strategies whenever possible and to avoid
The programs that you select should
harmful programs and those that have
be culturally appropriate for your communi-
been evaluated and found to lack any evi-
ty. Programs that reference urban situations
dence of effectiveness. In some cases, where
and cultural norms are likely to be inap-
an evidence-based or evidence-informed
propriate for a rural community. If a large
program is not available, you may need to
percentage of your community regularly
use or create a program that hasn’t yet been
participates in religious services, you may
evaluated. In this case, you will need to
want to include faith-based programs in
develop and conduct a robust evaluation of
your selection. If your community includes
your program, as described in the Evaluating
a significant population that is linguistically
Programs section on page 19.
or culturally distinct, you should ensure that
The programs that you select should
you include programs that are appropriate
match your target audience. A prevention
for that population.
program that has been found to be effec-
It is important to consider a mix of
tive for elementary-aged children might be
primary prevention, harm reduction, and
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