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Prevention Programs

INTRODUCTION

Two of the Comprehensive Addiction and Recovery Act (CARA) grant programs—Improving Access to Overdose Treatment (OD Treatment Access) and First Responder Training (FR-CARA)—are focused on preventing overdose. This chapter provides an overview of both programs, the outcomes and metrics they require from grantees, and the committee’s recommendations for outcomes and metrics that the Substance Abuse and Mental Health Services Administration (SAMHSA) should encourage or otherwise facilitate grantees in collecting and reporting in order to meet the goals of these two programs.

OD Treatment Access

The Center for Substance Abuse Prevention (CSAP) began accepting applications for the OD Treatment Access program in fiscal year (FY) 2017. The program aims to expand access to Food and Drug Administration (FDA)-approved drugs or devices for the emergency treatment of opioid overdose. Specifically, the grant program provides support for organizations or prescribers to develop best practices for prescribing and co-prescribing these drugs and devices, facilitates training for community stakeholders about drug overdose and overdose reversal drugs, and

ensures that patients who have experienced a drug overdose are connected with appropriate treatment.¹

To be eligible for OD Treatment Access funding, a potential awardee must be a federally qualified health center, an opioid treatment program, or a qualified practitioner dispensing narcotic drugs. In 2017, one grant was to be awarded at up to $1 million per year with no cost-sharing or matching requirements. In 2018, the grant funding was changed such that up to five grants were made available at up to $200,000 per year (again, with no cost-sharing or matching requirements). SAMHSA awarded five grants in FY2018; these programs began in September 2018. Project location, scope, and anticipated population effect vary by project.

The OD Treatment Access program requires that grantees use the funding to:

• Establish a program for prescribing a drug or device approved by FDA to treat opioid overdose;
• Train and provide resources for health care providers and pharmacists on the prescribing of such drugs or devices;
• Establish protocols to connect patients who have experienced a drug overdose with appropriate treatment, including medications, counseling, or behavioral therapy;
• Develop a plan for sustaining the program after federal support has ended;
• Use SAMHSA’s Opioid Overdose Prevention Toolkit² as a guide to develop and implement a comprehensive prevention program to reduce the number of opioid overdose-related deaths and adverse events; and
• Better understand and prevent overdose by patients on prescribed opioids (e.g., document and address potential drug interactions, any reductions in prescription dose, and evaluation for other substance issues, such as alcohol use disorders).

Other allowable activities include collaborating with other health care providers and pharmacists to provide education on overdose treatment drugs or devices, collaborating with pharmacies to distribute such drugs or devices, and providing public education about “Good Samaritan” laws

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¹ See https://www.samhsa.gov/grants/grant-announcements/sp-18-006 (accessed March 13, 2020).

² See https://store.samhsa.gov/product/Opioid-Overdose-Prevention-Toolkit/SMA184742 (accessed March 12, 2020).

related to drug overdose.³Table 2-1 offers a summary of the OD Treatment Access program.

Grantees are required to collect and report a standardized set of outcomes and metrics. First, grantees must use the CSAP Division of State Programs Management Reporting Tool (DSP-MRT) (described in more detail in Box 2-4). Second, grantees must collect and report an additional set of data using the OD Treatment Access Reporting Tool (described in more detail in Box 2-1).

Finally, grantees are required to conduct and report a local performance periodically. This assessment is designed to promote continual grantee improvement and help grantees determine whether they are meeting their goals, objectives, and outcomes, including on behavioral health disparities.

Grantees are allowed to use no more than 20 percent of the total award for (1) purchasing or distributing drugs or devices to treat overdose and (2) offsetting copayments or other cost sharing for such drugs or devices. In addition, no more than 20 percent of the total award can be used for data collection, performance measurement, and performance assessment. Box 2-2 shows the program’s current grantees.

FR-CARA

Similar to the OD Treatment Access program, SAMHSA’s CSAP began accepting applications for the FR-CARA program in FY2017. FR-CARA aims to encourage first responders and members of the community to administer drugs and devices for treating opioid overdose when necessary and to promote addiction treatment. This includes training and providing resources to those first responders (FRs) and community members and establishing processes, protocols, and mechanisms for connecting people to addiction treatment and recovery communities. Under this funding mechanism, FRs include “firefighters, law enforcement officers, paramedics, emergency medical technicians, or other legally organized and recognized volunteer organizations that respond to adverse opioid related incidents.”⁴

To be eligible for FR-CARA funding, a potential awardee must be a state, tribal organization (e.g., American Indian tribe, consortia of tribes, Alaska Native tribe), or local government (e.g., municipal, county, city,

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³ A majority of states have passed Good Samaritan laws, also referred to as “overdose immunity laws,” which provide legal immunity (e.g., from arrest for controlled substance possession or possession of paraphernalia) for an individual who seeks medical assistance for someone else who has overdosed from an opioid or other drug.

⁴ See https://www.samhsa.gov/grants/grant-announcements/ti-19-004 (accessed March 13, 2020).

TABLE 2-1 Summary of OD Treatment Access Program

^a See https://www.samhsa.gov/grants/grant-announcements/sp-18-006 (accessed March 13, 2020).

^b See https://www.samhsa.gov/grants/awards/2017/SP-17-006 (accessed April 21, 2020).

^c See https://www.samhsa.gov/grants/awards/2018/SP-18-006 (accessed April 21, 2020).

^d See https://store.samhsa.gov/product/Opioid-Overdose-Prevention-Toolkit/SMA18-4742 (accessed March 13, 2020).

town, borough). FR-CARA is structured as a Cooperative Agreement such that SAMHSA staff remain active participants in the implementation of grantees’ projects and provide technical assistance.

In 2017, up to 30 awards were to be granted with between $250,000 and $800,000 per year, depending on the recipient. States could be awarded up to $800,000, local governments up to $500,000, and tribes or tribal organizations up to $250,000 per year. No cost sharing or matching is required for the FR-CARA program. SAMHSA funded the first cohort of 21 projects in FY2017; an additional 28 projects were funded in FY2018 with off-the-shelf funding. The 49 total projects are a mix of recipient organizations: Native American tribes; emergency medical response service organizations; state, county, and local health departments; medical centers; health and wellness centers; municipalities; substance use treatment facilities; and a university.

The required activities under FR-CARA are to:

• Provide FRs and certain members of the community with drugs or devices to treat opioid overdose;
• Train and provide resources to those individuals to encourage proper administration of the drugs or devices; and
• Establish processes, protocols, and mechanisms to refer patients to treatment and recovery communities.

In addition, grantees must join or begin an advisory council consisting of representatives from the state, tribal, or local government leadership (e.g., governor’s office, tribal council representative) and a group of engaged stakeholders (e.g., other agencies seeking to prevent opioid overdose harm, FR organizations, representatives from treatment and recovery organizations, health care providers, harm-reduction groups, community health centers, pharmacies, or criminal justice system representatives). The purpose of this advisory council is to provide guidance to the grantee over the course of the grant and ensure the grantee is meeting its goals. Table 2-2 offers a summary of the FR-CARA program.

Other activities that are allowed under the FR-CARA grant but are not required include (1) educating health care providers on the dangers of overdose and empowering them to serve as a resource to patients and their families, and (2) providing public education on Good Samaritan laws. Similar to the OD Treatment Access program, grantees under the FR-CARA program are required to use and report on the CSAP DSP-MRT (described in more detail in Box 2-4).

FR-CARA grantees are required to conduct and report a local performance assessment at least once per year. This assessment is designed to promote continual grantee improvement and help grantees determine whether they are meeting their goals, objectives, and outcomes, including on behavioral health disparities. Grantees are allowed to use up to 20 percent of the federal funding for data collection, performance measurement, and performance assessment expenses and up to 10 percent of grant funds for administrative costs. Each grantee has yearly and 4-year goals on the extent to which overdose survivors and families receive information about treatment services and the number of responses to requests for training services, FRs equipped with naloxone, and opioid and heroin reversals. Grantees can decide who serves as an FR (e.g., this could be a teacher) and as a coordinator for immediate engagement in treatment and recovery services.

The DSP-MRT for the FR-CARA program aims to assess both the effectiveness of first responders (i.e., the number of times they have administered naloxone) and their attitudes and knowledge following grant-funded trainings (e.g., the number of them who completed a post-training survey, feel confident administering naloxone, and learned new information and skills because of the training). Box 2-3 shows the current program grantees.

TABLE 2-2 Summary of FR-CARA Program

^a See https://www.samhsa.gov/grants/grant-announcements/ti-19-004 (accessed March 13, 2020).

RECOMMENDATIONS

The committee recognizes that grantees may not have the resources to implement a wide range of new outcomes or metrics under the SAMHSA grant funding (particularly because they are limited to spending no more than 20 percent of grant funding on data-collection efforts). The committee also recognizes that SAMHSA reporting tools are developed for applicability to a range of programs and that these grants are for program implementation and training, not research. Nonetheless, it is the committee’s view that these outcomes and metrics collected should reflect the best available evidence on research metrics and outcomes related to opioid use. The following outcomes and metrics may assist SAMHSA in achieving its and grantees’ goals, provided that the resources exist to implement metric collection and reporting.

Fentanyl

One required activity under the OD Treatment Access grant program is that grantees must “develop and implement a comprehensive prevention program to reduce the number of prescription drug/opioid-related deaths.” Despite the DSP-MRT’s focus on education and training (for FRs and in high-need communities), there is no explicit focus on education for overdose due to fentanyl (though grantees are required to use Appendix B to report the cause-of-death code for various opioids, including synthetic opioids). In the section on overdose deaths involving any opioid, only prescription pain relievers, heroin, and opium are listed, even though fentanyl and its analogues are responsible for more overdose deaths in the United States than any other single drug (NIDA, 2020). Fentanyl test strips can be used by people who use drugs to detect whether it is present in these drugs. Studies have shown that test strips are useful and relatively easy to use by people who use drugs (Goldman et al., 2019). Another study of 125 people who use drugs demonstrated that 43 percent changed their behavior after use of a test strip and 77 percent felt safer having used a test strip (Peiper et al., 2019). In a third study of 93 participants who had completed a brief training about fentanyl test strips, 95 percent reported that they planned to use them (Krieger et al., 2018b). Though there may be regional variation in fentanyl supply, and some individuals may actually be seeking to use fentanyl because of a high tolerance to other opioids, these aforementioned references suggest that individuals who use drugs feel safer when using test strips and may therefore reduce the risk of overdose. In certain markets where fentanyl is ubiquitous, the utility of fentanyl test strips may be limited. Still, in markets where fentanyl is rarer, their use may prevent death due to overdose. The text of CARA

includes a provision for the Department of Health and Human Services to advance education and awareness of the public (including providers, patients, and consumers) about the dangerous effects of fentanyl, though the legislation does not explicitly direct SAMHSA to conduct this outreach in the context of the FR-CARA grant program (P.L. 114-198, Sec. 102).⁵

Recommendation 2-1: The Substance Abuse and Mental Health Services Administration (SAMHSA) should ensure that in education and outreach efforts across SAMHSA programs, including activities funded by the First Responder Training program and the Improving Access to Overdose Treatment program, a key outcome is the degree to which providers, first responders, and members of the public understand the danger associated with fentanyl and its analogues. SAMHSA should facilitate the distribution of fentanyl test strips along with naloxone—especially to regions with above-average overdose rates and in regions with relatively low penetration of fentanyl already—and should collect data on how many test strips were distributed and used.

Referral to Treatment

There are a range of treatments available to treat opioid use disorder (OUD) that have a solid backing of evidence; this includes, most relevantly, medication for OUD (MOUD) (i.e., buprenorphine, methadone, and naltrexone) (NASEM, 2019). A primary goal of the FR-CARA program is to “establish processes, protocols, and mechanisms for referral to appropriate treatment and recovery communities.”⁶ The DSP-MRT allows grantees to report on the number of individuals receiving treatment with MOUD, counseling, behavioral therapies, or other interventions. The reporting tool also contains sections where grantees can describe efforts to facilitate access to treatment and list the number of strategies developed to refer individuals to treatment. However, there are no stipulations in the FR-CARA program or the DSP-MRT that outline which treatments should be of highest priority. In addition to the requirement that grantees refer patients to appropriate treatment, a key outcome of the FR-CARA program should be that patients are referred to programs that are equipped to provide evidence-based treatment for OUD (NASEM, 2019).

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⁵ See https://www.congress.gov/bill/114th-congress/senate-bill/524/text (accessed March 13, 2020).

⁶ See https://www.samhsa.gov/grants/grant-announcements/sp-17-005 (accessed March 13, 2020).

Recommendation 2-2: The Substance Abuse and Mental Health Services Administration (SAMHSA) should support grantees in collecting and reporting data on the number of overdose survivors who initiate and are engaged in evidence-based opioid use disorder treatment. With technical assistance on evidence-based practices offered by SAMHSA, grantees should include information about the characteristics of the programs providing treatment and the evidence on which their treatment is based.

While it is a required activity of the FR-CARA grantees to connect overdose survivors with treatment—and that “overdose [survivors] and families receive information about treatment services and available data describing treatment admissions”—there is no stipulation in the DSP-MRT to report the time between referral and treatment initiation. It is known that the process of referral can be a barrier to effective and timely treatment (Blevins et al., 2018) and that rapid access to treatment can be effective in reducing substance use and increasing retention in treatment (NASEM, 2020; Oquendo and Volkow, 2018; Wiercigroch et al., 2020). This is especially important in light of the high rates of overdose due to synthetic opioids, as it stands to reason that the longer that an individual remains untreated, the longer they risk an additional overdose event. This is supported by evidence from individuals recently released from correctional facilities who are quickly engaged in OUD treatment (Green et al., 2018). A primary outcome of FR-CARA grantees should be to minimize the days between referral to evidence-based treatment and treatment initiation. In addition, the supplemental OD Treatment Access—Reporting Form has a section devoted to “connection to appropriate treatment.” As described for the FR-CARA program mentioned above, there are a range of available OUD treatments, some with more evidence to support them than others. “Connection” to treatment is a largely unquantifiable metric. As a result, grantees should have as a primary outcome that patients are referred to evidence-based treatment and initiate such treatment in a timely manner.

Recommendation 2-3: The Substance Abuse and Mental Health Services Administration should collect information that would provide a full understanding of the opioid use disorder treatment programs to which patients are referred, focusing on whether the treatments delivered are evidence based. Additionally, it would be important to understand the time between overdose, referral, and initiation of treatment. For grantees that cannot capture such data due to resource or technical constraints, a random sampling approach—or a systematic sampling approach if more appropriate for any given grantee

or population—should be used to track these metrics over time and identify where referral and engagement processes can be improved.

The FR-CARA DSP-MRT encourages grantees to partner with harm-reduction agencies, such as syringe service programs to distribute naloxone kits. However, there are no currently required outcomes or metrics related specifically to initiating harm-reduction services following an overdose. Some harm-reduction strategies, such as syringe service programs and MOUD, have proven effective at preventing the transmission of infectious diseases, especially when provided together (Aspinall et al., 2014; Platt et al., 2017) and may serve as an entry point for further medical care and treatment for OUD (NASEM, 2020). As part of its goal to increase referrals to treatment and recovery communities, the FR-CARA program could require that grantees connect overdose survivors with harm-reduction services in addition to treatment programs.

Recommendation 2-4: The Substance Abuse and Mental Health Services Administration should provide support to grantees to engage survivors of overdose in a full range of harm-reduction services (including syringe services programs and naloxone distribution services) and collect data on how many of these individuals end up engaging in harm-reduction services (e.g., number of individuals receiving a naloxone kit following an overdose event). Grantees could accomplish this by developing new services or by partnering with existing harm-reduction organizations.

Improved Knowledge About Patients and Areas Served

The DSP-MRT Disparity Impact Statement requires grantees to provide information about the population(s) experiencing disparities that the grantee aims to serve. This includes information about race/ethnicity, sex, gender, sexual orientation, age, location of residence, socioeconomic status and veteran, disability, and mental illness status. However, the disparities impact statement does not require grantees to report on insurance coverage or employment status in the selected population(s) or among those who were administered naloxone. In a 2020 study, Balio and colleagues demonstrated that patients who were uninsured or on Medicaid were more likely to experience an additional opioid-related emergency department (ED) encounter compared to those on private insurance (Balio et al., 2020). In the interest of preventing subsequent overdoses, it may be beneficial to focus efforts on Medicaid and uninsured populations, ensuring that these individuals are adequately engaged in OUD treatment. In addition, stable housing is an important correlate to a successful recovery

(Padgett et al., 2011) and should be measured in tandem with other client characteristics.

Recommendation 2-5: The Substance Abuse and Mental Health Services Administration should require information on insurance coverage and housing (or lack of coverage and housing) as additional metrics to be reported in grantees’ disparity impact statements in the Division of State Programs Management Reporting Tool. Grantees should collect and report repeated overdoses in all populations, with a particular focus on reducing overdoses among those on Medicaid and those who are uninsured or unstably housed.

In the FR-CARA DSP-MRT section on Naloxone Administration by Partner Organizations, grantees are required to report the location where naloxone was administered (e.g., in a private residence, a public park or shelter, an indoor public place or business). While the DSP-MRT requires that grantees define their high-need service areas, this definition only describes this term as a geographic service area “where the population has or is at risk of having a higher than average prevalence rate of prescription drug/opioid misuse, prescription drug/opioid overdoses, prescription drug/opioid overdose deaths, or adverse events related to prescription drug/opioid misuse.” However, grantees are not required to report the geographic location within the city, town, or county where specific overdoses have occurred. Without this information, it may be difficult for grantees to track specifically where overdoses are occurring and target those areas more effectively (e.g., in a particular 10-block radius or a specific building).

In addition, the FR-CARA DSP-MRT Overdose Outcomes section requires that grantees report on various grantee-level overdose data. This may include the number of ED visits involving opioid overdose, the number of hospitalizations, and the demographics of overdose survivors. However, a person who has received naloxone following an overdose may refuse to go to the ED or be hospitalized (Willman et al., 2017). In these cases, the primary source of information regarding the overdose is the FR who administered naloxone, rather than an ED or hospitalization event. The FR-CARA DSP-MRT provides a space where grantees can fill in information related to “Other Opioid Overdose Events (optional)” but no explicit place for a first responder’s report of the overdose if a patient refuses transport to the hospital. Having data on overdose rates (separate from ED visits) may help identify the program’s true effects, and distinctions between overdose rates and ED visits may be important for generating recommendations from program experience. Notably, law

enforcement officers who are first responders at an overdose event can share details about the overdose with national databases used for federal, state, and local public health efforts,⁷ though this granular information may not be readily accessible to grantees. In such cases, grantees should seek to sign memoranda of understanding wherever possible with emergency medical services agencies to share such information for the purpose of addressing service delivery gaps. If such memoranda are not possible, it would be important to clarify the potential limitations of reported rates (e.g., that they may not include all overdoses).

Recommendation 2-6: The Substance Abuse and Mental Health Services Administration (SAMHSA) should support grantees in collecting geographic locations of overdoses (such as zip codes) to identify gaps in services and prevent future overdoses. These data should be used to help grantees identify the reach of their activities and provide a benchmark to improve on. In addition, SAMHSA should support grantees in collecting data on nonfatal overdoses in coordination with first responders where transportation to the hospital does not occur (including on how many times naloxone was administered and who administered it).

Naloxone Training

While education and training on naloxone does improve knowledge among non-medical members of the public (Giglio et al., 2015), there is mixed evidence that awareness, knowledge, and access to naloxone are entirely sufficient to guarantee that individuals routinely carry or use it when needed (Fairbairn et al., 2017; Kerensky and Walley, 2017; Tobin et al., 2018; Walley et al., 2013). Tracking whether members of the community are carrying and using naloxone may be difficult for grantees due to resource limitations, though partnerships with local harm-reduction agencies that collect these data (or EDs that collect these data after a patient is admitted) may serve as a facilitator.

Recommendation 2-7: In addition to measuring the number and characteristics (e.g., friend/family member of a person who uses drugs) of trained individuals who feel confident administering naloxone in the case of an overdose, the Substance Abuse and Mental Health Services Administration should support grantees that focus on training laypeople or a community organization/agency/staff in measuring

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⁷ See http://www.odmap.org (accessed April 21, 2020).

the extent to which individuals actually administer naloxone when needed and whether their knowledge and skills in administering naloxone has been improved by the program’s activities.

OD Treatment Access grantees are required to “train and provide resources for health care providers and pharmacists on the prescribing of drugs” to reverse overdose. However, given the scale of the opioid epidemic and the lack of providers available to address the needs of those with OUD (NASEM, 2020), broadening the scope of training to include students (e.g., medical, nursing, social work, and pharmacy students) would increase the future supply of professionals who are trained on prescribing and co-prescribing naloxone.

Recommendation 2-8: The Substance Abuse and Mental Health Services Administration should develop efforts within these grant programs to include medical, nursing, social work, and pharmacy students in training sessions on prescribing and co-prescribing of naloxone and should collect data and report on the number of students trained.

FR Compassion Fatigue

FRs may be especially susceptible to compassion fatigue, as they are often the first point of contact to patients experiencing an opioid overdose. Pike and colleagues have demonstrated that the opioid epidemic has resulted in increased workload, compassion fatigue, and negative emotional effects among FRs (Pike et al., 2019). One-third of those in this study exhibited high compassion fatigue scores on a questionnaire, and 95 percent said that the opioid epidemic has affected their profession. Still, nearly all the FRs recognized that their roles were important in addressing the opioid epidemic—another study has shown that naloxone administration by FRs is associated with reduced overdose mortality (Rando et al., 2015). Given the important role that FRs can play in reversing overdose and connecting patients with treatment, it is important to maintain job satisfaction and retention among this workforce; this could include feedback to FRs from individuals who have been saved by an FR, increased recognition of FRs, or—importantly—improving relationships between community members and FRs (Koester et al., 2017; Wagner et al., 2019).

Recommendation 2-9: The Substance Abuse and Mental Health Services Administration (SAMHSA) should assess first responder job satisfaction and rates of compassion fatigue or turnover due to overdose prevention as key outcomes of the First Responder Training

program. SAMHSA should routinely assess progress toward these outcomes among first responders who are beneficiaries of the grant. Surveys of first responders can be used to elucidate job satisfaction and feelings of compassion fatigue and to assess the extent to which opioid-related events impact their sentiments about their work (surveys, however, should be as brief as possible to elicit the necessary information, thereby reducing undue administrative burden). Rates of first responder turnover can be assessed through reviews of administrative data at the state and local levels. Furthermore, SAMHSA should support grantees in establishing mechanisms for maintaining job satisfaction and preventing compassion fatigue among first responders.

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