What is the Program?
The Overdose Prevention Project provides people who inject drugs and their social networks with strategies for avoiding overdosing, including access to naloxone and training in how to administer the substance. The project also builds awareness among professionals who come into contact with people who inject drugs (such as police, paramedics and other medical professionals) about overdose prevention and the administration of naloxone.
Streetworks, the only needle exchange program in Edmonton that runs out of five locations and operates a van for evening outreach work, administers the Overdose Prevention Project. There are six staff members (four nurses and two outreach workers) in the core program, which is funded through the Alberta Community HIV Fund (ACHF) with a contribution for supplies by Alberta Health Services.
While encountering people who inject drugs through other outreach efforts, the Streetworks staff identifies clients who are opiate users (or people in their social networks) as potential candidates for participation in the Overdose Prevention Project. Each participant completes a brief, yet comprehensive, training in artificial respiration and naloxone administration before being given an overdose prevention kit, which includes two doses of naloxone. Participants are now able to provide preliminary emergency care for fellow drug users in the event of an overdose prior to seeking professional medical attention.
Why Was the Program Developed?
The Overdose Prevention Project emerged from Streetworks, which began as “Needleworks” in 1989, when eight city agencies met to address the issue of HIV among injection drug users and sex trade workers with needle exchange intervention. Streetworks has evolved into a multi-service outreach program for harm reduction and primary health care education.
During the first years of Streetworks’ existence, outreach staff noticed a number of health concerns affecting the people they served. It immediately became obvious that the target population needed a very broad, comprehensive range of services and in 1995 nurses were brought on to the team.
Until Streetworks created its Overdose Prevention Project in 2005 there were no specific harm reduction programs that aimed to decrease overdoses and death by overdoses in Alberta, yet the Alberta Medical Examiner’s office reported more than 300 cases of death due to overdose from opiates or cocaine in 2003.
Meanwhile, the Alberta Non Prescription Needle Use project, which includes a consortium of 39 agencies including federal and provincial representatives, had identified harm reduction programming as critical to reaching youth, persons of Aboriginal descent and those with mental health issues. Overdose deaths were identified as an emerging issue within the province, particularly among the population served by Streetworks.
Due to the legal nature of injection drug use, people who inject drugs are often the only witnesses present when one of their fellow users overdoses. Many are reluctant to call the Emergency Response Department, as they are fearful of arrest since drug-related ambulance calls are usually accompanied by police. Given this vulnerability, training people who inject drugs in the administration of naloxone to reverse opiate overdose can be an effective way of preventing death by overdose among this highly vulnerable population.
The idea of using naloxone at a community level was inspired by the work of the Chicago Recovery Alliance, which reported that approximately 10% of the people trained by the organization to administer the substance used it to prevent an overdose in the first year. Watch a video from the Chicago Recovery Alliance about how naloxone works.
Initial funding for the project included a budget for developing a drug handbook and an overdose awareness campaign, elements of which are used as educational tools with participants. Though specific funding for the project was terminated in 2007, the Streetworks’ council determined that the project was critical and continued operating it through donations, by reallocating resources from other projects and by dividing up the responsibilities for maintaining the project across Streetworks staff.
How Does the Program Work?
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.
The Impact of Compassion
People who use injection drugs tend to be alienated from mainstream resources and are often struggling with unemployment, homelessness, the criminal justice system and less than optimal health. Mental health issues are prevalent among people who inject drugs, yet little is known on the street about depression, schizophrenia, bipolar disorder, antisocial personalities, dementia, paranoia, obsessive-compulsiveness, etc. Many people self-medicate with illicit drugs to treat their underlying mental health disorders.
A program like Streetworks may provide the only place that a person who injects drugs can go where he or she is treated as an intelligent human being worthy of respect. The program’s Overdose Prevention Project calls on participants to become active in their own care. This approach works well at a community level, as this particularly vulnerable community of substance users tends to feel unable, unworthy or untrusting of more mainstream support networks. Consequently, they are inclined to turn to each other for support, and will have more capacity to assist themselves and each other when they are equipped with the necessary training and tools.
Streetworks Client Statistics in 2009:
- 63% were of Aboriginal descent
- 3.5% of Streetworks clients were 19 and under
- 38.6% of Streetworks clients were street-involved women
“We have always found that when we work with a community member group, the health of the group is greatly enhanced. Many people come to understand that they are valuable and intelligent, and often this leads to people stabilizing their lives, becoming more moderate in their drug use or quitting their drugs. Also highlighted is the thirst for knowledge demonstrated by community members. Over and over, this vulnerable population helps each other out, as they feel unable, unworthy or untrusting of the present systems. Enhancing their ability to care for themselves and each other underlines the principles of population health, health promotion and primary health care.”
Marliss Taylor, Program Director, Streetworks
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.
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.
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.
As the Overdose Prevention Project currently receives no funding, the continuation of the project relies entirely on the following Streetworks staff taking on additional responsibilities in their existing roles whenever possible:
Oversees staff, keeps stock of naloxone, keeps informed about international developments in harm reduction
Comfortable working with target clientele in a respectful, nonjudgmental way; train participants to administer naloxone
Comfortable working with target clientele and good at motivating them to participate in training
Though not on staff, the program must have a close connection with a physician who is capable and willing to write prescriptions for naloxone knowing that the person to whom it is given may administer it to a peer who has overdosed rather than to him or herself. Physicians who haven’t worked with people who use injection drugs may not understand the need for members from this community to administer naloxone on their own, so finding a physician familiar with this population is critical.
- Print resources for distribution to participants: “Uptown, Downtown: The Drug Handbook,” “Vein Care,” “Street First Aid” and brochures on sexually transmitted diseases
- Promotional posters (which can be as simple as black and white photocopies)
- Video: “Any Positive Change”
- Prescriptions for naloxone (obtained by Streetworks from local physicians)
- Two doses of naloxone per person
- Overdose kits that contain the naloxone doses as well as needles and syringes, alcohol wipes, rescue masks, gloves and cue cards
- Wallet cards explaining the reason for the participant to be in possession of naloxone
As Streetworks has not been able to secure ongoing funding for the Overdose Prevention Project, the project has been maintained by keeping costs to a minimum. The cost of printing of the posters and pamphlets, for example, has been kept to a negligible amount by keeping them as basic as possible (they are created in a word processing program and photocopied as needed).
Staff members offer the 20- to 25-minute overdose training to Streetworks clients who may benefit from it at the same time these clients contact or are contacted by Streetworks staff for other services. With the exception of naloxone, the overdose kits are assembled from items that are distributed as part of Streetworks’ other programming.
The only additional expenses incurred by the project are for naloxone and the cost of producing the drug handbook. Currently, with an estimated cost of $20-$25 per dose of naloxone, Streetworks spends approximately $1,800 on naloxone per year (estimated 80 doses per year). Streetworks also spends $6,000 per year to print the drug handbooks. These amounts are currently covered through private donations and organizational reserves.
- Obtaining sufficient ongoing funding to maintain a steady supply of naloxone to maintain the program
- Obtaining a sufficient supply of naloxone on an ongoing basis at a feasible cost
- Legalities associated with injection drug use that make it difficult to reach target clientele
- Earning the buy-in of emergency workers, especially police, who may be unfamiliar with naloxone
An internal evaluation of the Overdose Prevention Project that surveyed Streetworks staff, project partners and emergency workers, showed that between 2005 and 2007 the project trained had 50 individuals in artificial respiration and naloxone administration, which led to nine overdose reversals. Consequently, despite the lack of funding, the program’s council has determined the program should be maintained to whatever extent possible given that it has proven to be crucial in saving lives.
The Streetworks program as a whole was shown to be effective in a 2003 study through the Alberta Health Services’ (formerly Capital Health Region) Health Innovation Fund, which demonstrated that from 2000 to 2003, when the Streetworks program was double in size, there was a decrease in the number of ambulance calls and the number of days spent in acute care beds by people who use injection drugs, as well as an increase in the number of “appropriate” visits to hospital emergency rooms by people who inject drugs (visits that were reasonable responses to the health state of the individual in question). In 2009, there were 20,444 visits to Streetworks’ centres and 701,403 needles were distributed.
Moving forward, the Streetworks program is working on integrating a system of evaluation into the project, drawing on program records, contact sheets, evaluation with program users, anecdotal reports, meeting minutes, partner feedback and the project nurse’s journal. Ongoing monitoring will provide opportunity for continuous reflection and practice changes.
- Due to their social and legal vulnerability, people who use substances can be reluctant to call for official help in the event of a community member’s overdose, so training this community to administer its own emergency care in the event of an overdose is an essential component of harm reduction.
- Empowering people who inject drugs to administer their own emergency care (for themselves or other people who use injection drugs) in the event of an overdose can reduce the number of days spent by drug users in acute care and decrease the number of unnecessary emergency room visits.
- Teaching people who inject drugs to administer their own care and care for others can empower them to be more conscious of their drug use and its potentially deadly effects, at times serving as a catalyst for further change.
- Building awareness among police is an essential component of any program working with naloxone.
- Emergency health workers, while familiar with naloxone in general, may be unfamiliar with how it can be used by people who use drugs as a tool for harm reduction, making outreach to these workers an important component of the program.
For more information on the Overdose Prevention Project, please contact: