Programming Connection

Overdose Prevention Project 

Streetworks
Edmonton, Alberta
2010

How Does the Program Work?

Location

Although there is a high incidence of injection drug use throughout Edmonton, Streetworks’ services are centred in the urban core, where the need is most concentrated. Streetworks has five daytime fixed sites, of which two are primary sites. The program has a van that operates five to six evenings per week. Staff members also go out on foot to do outreach to clients during the day.

Outreach workers may engage a person who uses injection drugs in the Overdose Prevention Project at any time at any of the locations it serves, providing there is an appropriate nurse available. Overdose prevention training, likewise, may happen at any time or place. Due to the chaotic nature of the lives of many people who use injection drugs, outreach staff must be very flexible and conduct training whenever and wherever possible to take advantage of any window of opportunity for education.

Recruitment and Engagement

People who inject drugs

Participants may hear about the project and its benefits through staff outreach, word of mouth (i.e., from people with whom they inject drugs) or through flyers/brochures distributed in key areas of the city. Often a participant who is first drawn to Streetworks for access to free clean needles, condoms and other supplies returns to the program to take advantage of additional services such as the Overdose Prevention Project.

When providing services to a person who uses injection drugs, the Streetworks staff determines if he or she is an opiate user (or a person in the social network of an opiate user) and therefore a possible candidate for the overdose prevention training. Once Streetworks staff has determined that a person is an opiate user or a close social contact, a nurse explains how he or she can benefit from the training—explaining that it could save his or her life or the life of a friend—and assesses the individual’s readiness to participate. As long as an individual is sufficiently interested, coherent and willing to spend the 20-25 minutes it takes to complete training, he or she will be allowed to participate.

Emergency workers

Streetworks has a long-standing relationship with both Alberta Health Services (which maintains and governs Emergency Medical Services in the province) and the Edmonton police. A member of the police department is on the Streetworks council, and Streetworks gives a PowerPoint presentation on the Overdose Prevention Project to each new group of paramedics. 

While it is generally difficult to engage the police in a face-to-face training, the police department has been open to having information on the Overdose Prevention Project distributed annually to police staff in the form of an email. Health workers are generally enthusiastic to learn more about the project. 

Intervention

Once an individual expresses interest and the nurse has determined that he or she is sufficiently engaged (i.e., coherent and responsive) to benefit from participation in the project, the nurse guides the participant through the 20- to 25-minute overdose prevention training. Whenever possible, the training happens immediately after the individual has been recruited to the program. Due to the chaotic nature of the lives of many people who use injection drugs, it is difficult to plan follow-up meetings.

The training begins with a discussion of the participant’s preconceptions of what an overdose looks like and what they would do to care for an individual experiencing an overdose. This gives the nurse an opportunity to evaluate the individual’s baseline knowledge, correct any erroneous information and tailor the training more to the individual’s situation. 

Next, the nurse will go over various tips on how to prevent an overdose, such as doing a test dose and avoiding mixing their drugs with other “downers” or alcohol. These points are crucial to stress with participants, as primary prevention is an essential component of the program. The participant is then educated to recognize the signs and symptoms of a true drug overdose in both themselves and in others. At this point the video “Any Positive Change,” developed by the Chicago Recovery Alliance, is played as an introduction to naloxone: what it is, how it works, what street drugs it works to reverse (and which ones it doesn’t work for) and how to administer it safely and effectively. Once the video is complete, the nurse explores and expands upon the content, answering any questions the individual may have.

Each participant is then taught the mechanics of how to draw up and administer naloxone (to themselves or possibly to their peers). Potential side effects are discussed as well as guidelines for aftercare. A patient waking up from an overdose after having naloxone administered can be extremely agitated and irritable, and participants are taught about the kinds of reactions they can expect. Since death in the event of opiate overdose is usually caused by stopped breathing and subsequent lack of oxygen, and since it takes several minutes to achieve results after administering naloxone, the nurse also trains each participant to administer artificial respiration (AR) after administering the substance. For more information on the tips offered in training, contact Streetworks.     

The kit that participants are provided includes two doses of naloxone (some people who overdose require a second dose of naloxone to begin overdose reversal), needles (the appropriate size for intramuscular injections), syringes, alcohol wipes, a rescue breathing barrier mask, gloves and cue cards that serve as reminders for the steps of administering AR and naloxone. A wallet card, which denotes the reason for the person to be in possession of naloxone, is also provided.

Participants are encouraged to come back in a year to renew training and have the nurse check naloxone expiry dates. In the event a participant administers a dose of naloxone before the end of the year, he or she is asked to come back for support and to replenish the supply of naloxone.

Emergency Workers

The Overdose Prevention Project includes awareness building for emergency workers, such as those who work in emergency rooms, Emergency Medical Services and the Edmonton Police. Outreach may be very brief (as in an email sent to all workers) or more involved (as in a three hour-long PowerPoint presentation for all personnel).

Awareness building is an especially critical component of the program for emergency health workers, as they may have contact with a patient who has had naloxone administered. While health workers are familiar with naloxone in an institutional context where the substance is administered to patients who have overdosed, they may not immediately understand the need for its use by injection drug users. Administering naloxone is not unlike giving epinephrine to someone who is allergic to a bee sting. It is not an addictive drug and has no use other than reversing opiate overdose.

By building awareness of the Overdose Prevention Project and the administration of naloxone by people who use injection drugs, emergency workers can more effectively work with anyone who administers the drug to someone who has overdosed, improving their ability to help the patient.

The police must also be made aware of the project. If they are not, it is possible that people will have their naloxone confiscated if they come into contact with police, whether or not they have other substances in their possession.