Guide to Developing
`and Managing
`Overdose
`Prevention
`and Take-Home
`Naloxone
`Projects
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`Guide To Developing and Managing
`Overdose Prevention and Take-Home
`Naloxone Projects
`
`Harm Reduction Coalition
`
`For more information on Harm Reduction Coalition’s
`overdose prevention projects, please visit our website:
`
`http://harmreduction.org/our-work/overdose-prevention/
`
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`Published Fall 2012
`
`Supported in part by M.A.C AIDS Fund.
`
`Written by: Eliza Wheeler, Katie Burk, Hilary
`McQuie, and Sharon Stancliff
`
`Edited by: Emily Winkelstein
`
`Images and photographs courtesy of:
`Maya Doe-Simkins, Mary Wheeler, Joanna
`Berton Martinez, N.O.M.A.D (Not One More
`Anonymous Death), Nabarun Dasgupta and
`Roxanne Saucier.
`
`Many thanks to the following individuals
`and programs not only for their valuable
`contributions to this manual, but also for
`their leadership, wisdom, guidance and
`creativity throughout the years:
`
`Dan Bigg and CRA, Alice Bell and Preven-
`tion Point Pittsburgh/Overdose Preven-
`tion Project, Mary Wheeler and Healthy
`Streets/N.O.M.A.D., Lisa Raville and the
`Harm Reduction Action Center, Steve Alsum
`and The Clean Works program of The Grand
`Rapids Red Project, Joanne Peterson and
`Learn To Cope,  Mindy Domb and SPHERE
`Health Imperatives, Mik Hennessy and SOS,
`Fred Wells Brason, Nabarun Dasgupta and
`Project Lazarus, Alex Walley, Sarah Ruiz and
`the Massachusetts Overdose Education and
`Naloxone Distribution Program, Scott Burris,
`Leo Beletsky, Roxanne Saucier, Deborah
`Milbauer, Joanna Berton Martinez, Peter
`Davidson, T. Stephen Jones, Kevin Irwin,
`Alex Kral, Heather Edney (and the Santa
`Cruz Needle Exchange), and Anne Siegler.
`
`Many thanks to the NOPE Working Group,
`and to the overdose prevention and
`naloxone programs in the US for sharing
`their materials, stories and experiences with
`us! Also, extra special thanks to Maya
`Doe-Simkins for contributing so much to the
`writing of this manual, and for your tireless
`work on overdose prevention. Thank you.
`
`The Harm Reduction Coalition is a national
`advocacy and capacity-building organiza-
`tion that promotes the health and dignity
`of individuals and communities impacted
`by drug use. Harm Reduction Coalition
`advances policies and programs that help
`people address the adverse effects of drug
`use including overdose, HIV, hepatitis C,
`addiction, and incarceration. We recognize
`that the structures of social inequality
`impact the lives and options of affected
`communities differently, and work to uphold
`every individual’s right to health and well-
`being, as well as in their competence to
`protect themselves, their loved ones, and
`their communities.
`
`http://harmreduction.org
`
`East Coast:
`22 West 27th Street, 5th Floor
`New York, NY 10001
`tel. 212-213-6376
`fax. 212-213-6582
`hrc@harmreduction.org
`
`West Coast:
`1440 Broadway, Suite 510
`Oakland, CA 94612
`tel. 510-444-6969
`fax. 510-444-6977
`hrcwest@harmreduction.org
`
`Layout and design by Imaginary Office
`http://www.imaginaryoffice.com
`
`This publication was supported by Coopera-
`tive Agreement Number PS09-906 from the
`Centers for Disease Control and Prevention.
`Its contents are solely the responsibility
`of the authors and do not necessarily rep-
`resent the official views of the Centers for
`Disease Control and Prevention.
`
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`Contents
`
`Introduction
`
`Using this Guide
`
`Module 1:
`Understanding the Basics p.9
`
`What is Overdose? p. 9
`
`What is Naloxone? p. 9
`
`The Need for Take-Home Naloxone
`Programs p. 11
`
`Module 2:
`Overdose Prevention Strategies
`without Naloxone p.13
`
`Integrate Overdose Prevention Messages as
`Standard Practice p. 14
`
`Develop an Onsite Overdose Response
`Policy p. 14
`
`Provide Overdose Response Training to
`Participants p. 14
`
`Module 3:
`Take-Home Naloxone Program
`Development p.17
`
`Community Assessment, Outreach and
`Engagement p. 17
`
`Legal Considerations p. 21
`
`The Role of Medical Professionals p. 22
`
`Venues and Tips for Different Settings p. 26
`
`Module 4:
`Program Implementation and
`Management p.43
`
`Funding p. 43
`
`Purchasing and Storing Naloxone p. 43
`
`Assembling Kits p.46
`
`Data Collection and Paperwork p. 46
`
`Policy and Procedure Manuals p. 48
`
`Trainings p. 49
`Outreach Strategies p. 50
`
`Module 5:
`Overdose Prevention and
`Response p.53
`
`Risks and Prevention Strategies p. 53
`
`Overdose Recognition p. 57
`
`Responding to Opioid or Depressant
`Overdose p. 58
`
`Stimulant Overdose: Overamping p. 64
`
`Responding to Upper or Stimulant
`Overdose p. 66
`
`Module 6:
`Frequently Asked Questions p.69
`
`Appendix
`Available online at
`http://harmreduction.org
`
`Overdose Prevention and Response
`Messages
`
`Sample Documents
`
`Naloxone Kit Materials
`
`Training Materials
`
`Public Policy
`
`Research Bibliography
`
`Additional Resources
`
`Case Studies:
`
`1. Harm Reduction Action Center,
`Denver, CO p. 16
`
`2. Chicago Recovery Alliance,
`Chicago, IL p. 18
`
`3. DOPE Project,
`San Francisco, CA p. 24
`
`4. Clean Works,
`Grand Rapids, MI p. 27
`
`5. Prevention Point,
`Pittsburgh, PA p. 32
`
`6. Learn to COPE and the NOMAD Project,
`Statewide, MA p.36
`
`7. Duquesne University School of
`Pharmacy’s Center for Pharmacy
`Services,
`Pittsburgh, PA p. 39
`
`8. Project Lazarus,
`Wilkes County, NC p. 40
`
`9. Massachusetts Overdose Education and
`Naloxone Distribution,
`Statewide, MA p. 44
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`Introduction
`
`Drug overdose is the leading cause
`of injury death in the United States,
`causing more deaths than motor
`vehicle crashes. According to the
`Centers for Disease Control and
`Prevention (CDC), overdose rates
`have increased roughly five-fold
`since 1990. The CDC attributes
`the rise in drug overdose deaths
`to a higher use of prescription
`painkillers and increasing numbers
`of overdoses from cocaine and
`prescription sedatives. In 2008,
`the most recent year for which
`data is available, the CDC reports
`36,500 poisoning deaths in the
`United States.1
`
`Providing overdose prevention,
`recognition, and response
`education to drug users and their
`neighbors, friends, families, and
`the service providers who work
`with them is a harm reduction
`intervention that saves lives.
`Heroin and other opioid overdoses
`are particularly amenable to
`intervention because risk factors
`are well understood and there is a
`safe antidote — naloxone.
`
`Using this Guide
`
`This manual is designed to outline the
`process of developing and managing
`an Overdose Prevention and Education
`Program, with or without a take-home
`naloxone component. Overdose pre-
`vention work can be easily integrated
`into existing services and programs
`that work with people who use or are
`impacted by drugs, including shelter
`and supportive housing agencies, sub-
`stance abuse treatment programs, par-
`ent and student groups, and by groups
`of people who use drugs outside of a
`program setting. It offers practical sug-
`gestions and considerations rooted in
`harm reduction - an approach to drug
`use that promotes and honors
`the competence of drug users to
`protect themselves, their loved ones,
`and their communities and the belief
`that drug users have a right to respect,
`health and access to life-saving tools
`and information.
`
`This manual begins with a description
`of how to integrate overdose preven-
`tion education into existing programs.
`Next, it goes into detail about how to
`develop and manage a take-home nal-
`oxone program. The manual uses case
`
`studies of existing overdose preven-
`tion programs to outline main points
`and provide models. The manual also
`includes a comprehensive “Overdose
`Prevention and Response,” section
`which provides details on overdose
`and its causes and co-factors; over-
`dose recognition basics; and effective
`responses. An extensive Appendix is
`available online and includes anno-
`tated citations of existing research
`studies, examples of data track-
`ing forms, examples of policies and
`procedures, examples of PowerPoint
`presentations for overdose prevention
`trainings/groups, and other overdose
`materials.
`
`This manual is simply a guide. It is not
`meant to be exhaustive nor prescrip-
`tive, and there are numerous other
`resources that go into extended detail
`about many of the topics covered. We
`have provided links to these resources
`whenever possible. Take from this
`manual the parts that are important
`and meaningful to you, adapt them
`how you see fit, leave those pieces that
`may not apply, and pass on to others
`what you develop.
`
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`Introduction Notes
`1. Warner M, Chen LH, Makuc DM, et al.
`Drug poisoning deaths in the United
`States, 1980-2008. http://www.cdc.
`gov/nchs/data/databriefs/db81.htm.
`Published December 2011. Accessed
`September 20, 2012.
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`Module 1:
`Understanding the Basics
`
`What is Overdose?
`
`Overdose (OD) happens when a toxic
`amount of a drug, or combination of
`drugs overwhelms the body. People can
`overdose on lots of things, including
`alcohol, Tylenol®, opioids or a mixture
`of drugs. Mixing heroin, prescription
`opioids (like Oxycontin®, fentanyl,
`morphine, Vicodin®, Percocet®, etc.)
`and other downers such as alcohol
`and benzodiazepines (like Xanax®,
`Klonopin®, Valium®, Ativan®, etc.)
`are a particularly dangerous combo,
`since they all affect the body’s central
`nervous system, which slows breath-
`ing, blood pressure, and heart rate,
`and in turn reduces body temperature.
`Stimulant drugs like speed, cocaine,
`and ecstasy raise the heart rate, blood
`pressure, and body temperature, and
`speed up breathing. This can lead to a
`seizure, stroke, overheating, or heart
`attack. Overamping is the term we
`have begun using to describe what one
`might consider an “overdose” on speed.
`See page 64 for more information.
`
`Opioid overdose occurs when the level
`of opioids, or combination of opioids
`and other drugs, in the body render a
`person unresponsive to stimulation
`or cause their breathing to become
`inadequate. This happens because
`
`opioids fit into the same receptors
`in the brain that signal the body to
`breathe. If someone cannot breathe or
`is not breathing enough, oxygen levels
`in the blood decrease causing the lips
`and fingers turn blue, a process called
`cyanosis. Oxygen starvation will even-
`tually stop vital organs like the heart,
`then the brain, and can lead to uncon-
`sciousness, coma, and possibly death.
`Within 3-5 minutes without oxygen,
`brain damage starts to occur, soon fol-
`lowed by death.
`
`In the case of opioid overdose, survival
`or death wholly depends on maintain-
`ing the ability to breathe and sustain-
`ing oxygen levels. Fortunately, this
`process is rarely instantaneous; most
`commonly, people will stop breathing
`slowly, minutes to hours after the drug
`or drugs were used. While people have
`been “found dead with a needle in their
`arm,” in most cases there is time to
`intervene between when an overdose
`starts and before a victim dies. Even
`in cases where a person experiences
`overdose immediately after taking a
`drug, proper response can reverse the
`overdose and keep the person breath-
`ing and alive.
`
`What is Naloxone?
`
`Naloxone (also known by the brand
`name Narcan®) is a medication called
`an “opioid antagonist” and is used to
`counter the effects of opioid over-
`dose, for example morphine or heroin
`overdose. Specifically, naloxone is used
`in opioid overdose to counteract life-
`threatening depression of the central
`nervous system and respiratory system,
`allowing an overdose victim to breathe
`normally. Naloxone is not a controlled
`substance (i.e., non-addictive), pre-
`scription medication. Naloxone only
`works if a person has opioids in their
`system; the medication has no effect
`if opioids are absent. Although tradi-
`tionally administered by emergency
`response personnel, naloxone can be
`administered by minimally trained
`laypeople, which makes it ideal for
`treating overdose in people who have
`been prescribed opioid pain medication
`and in people who use heroin and other
`opioids. Naloxone has no potential for
`abuse.
`
`How Naloxone Works
`The brain has many receptors for
`opioids. An overdose occurs when too
`much of any opioid fits into too many
`receptors slowing then stopping the
`
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`What is an opioid overdose?
`The brain has many receptors for opioids. An overdose occurs when too much of any
`opioid, like heroin or Oxycontin®, fits in too many receptors slowing and then stop-
`ping the breathing.
`
`Opioids fit exactly on receptor
`
`Naloxone reversing an overdose
`Naloxone has a stronger affinity to the opioid receptors than opioids like heroin or
`Percocet®, so it knocks the opioids off the receptors for a short time. This allows the
`person to breathe again and reverses the overdose.
`
`Naloxone has a stronger
`affinity for receptor
`
`For a comprehensive overview of overdose prevention, recognition and response, please see
`Module 5: Overdose Prevention and Response. Adapted from graphic by Maya Doe-Simkins
`
`10
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`In most jurisdictions naloxone is only
`used in hospital settings and car-
`ried by emergency medical person-
`nel; as a result, it is only available to
`people experiencing overdose if and
`when emergency medical services
`are accessed. However, recognizing
`that many fatal opioid overdoses are
`preventable, take-home naloxone
`programs have been established
`in approximately 200 communities
`throughout the United States. These
`vital programs expand naloxone access
`to drug users and their loved ones by
`providing comprehensive training on
`overdose prevention, recognition, and
`response (including calling 911 and res-
`cue breathing) in addition to prescrib-
`ing and dispensing naloxone.
`
`According to a survey conducted in
`2010 by the Harm Reduction Coalition
`of known naloxone distribution pro-
`grams, between 1996 and June 2010,
`a total of 53,032 individuals have been
`trained and given naloxone as a result
`of the work of programs the US. These
`48 take-home naloxone programs,
`spread over 188 sites in 15 US states
`and DC, have received reports of 10,071
`overdose reversals using naloxone.2
`
`breathing. Naloxone has a stronger
`affinity to the opioid receptors than
`many opioids (like heroin, Oxycontin®
`or Percocet®) so it knocks the opioids
`off the receptors for a short time. This
`allows a person to breathe again and
`reverses the overdose.
`
`Naloxone may be injected in a muscle,
`vein or under the skin, or sprayed into
`the nose. Naloxone that is injected
`comes in a lower concentration
`(0.4mg/1ml) than naloxone that is
`sprayed up the nose (1mg/1ml). It is a
`temporary drug that wears off in 30-90
`minutes.
`
`The Need for Take-Home
`Naloxone Programs
`
`Studies indicate that many people
`who die from opioid overdose failed
`to receive proper medical attention
`because their peers and other wit-
`nesses (often other drug users) delay or
`do not call 911 for fear of police involve-
`ment.1 While not all opioid overdoses
`are fatal, the provision of naloxone by
`laypeople to an overdosing person who
`would otherwise not receive medical
`intervention saves hundreds of lives
`each year. Additionally, timely provision
`of naloxone may help reduce some of
`the morbidities (i.e. medical complica-
`tions or conditions) associated with
`non-fatal overdose. Witnesses who are
`able to perform rescue breathing and
`administer naloxone to an overdos-
`ing person experiencing respiratory
`depression will likely prevent brain
`damage and other harms.
`
`11
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`Module 1 Notes
`1. Pollini et al, 2005; Tobin et al, 2005;
`Davidson et al, 2003; Seal et al,
`2003; Strang et al, 2000.
`Amy S.B. Bohnert, Kathryn Roeder,
`Mark A. Ilgen, “Unintentional
`overdose and suicide among sub-
`stance users: A review of overlap
`and risk factors.” Drug and Alcohol
`Dependence. 110.3 (2010) 183-192.
`Print.
`2. Responses were collected from
`known naloxone distribution
`programs between October 5,
`2010-November 12, 2010 using a
`Survey Monkey survey tool by Eliza
`Wheeler, DOPE Project Manager at
`the Harm Reduction Coalition. The
`survey was initiated as a project of
`the NOPE Working Group (Naloxone
`Overdose Prevention Education)
`in order to gather up-to-date data
`about the impact of US naloxone
`distribution programs. Published
`in the CDC Morbidy and Mortality
`Weekly Report, “Community-
`Based Opioid Overdose Prevention
`Programs Providing Naloxone —
`United States, 2010,”February 17,
`2012 / 61(06);101-105.
`
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`Module 2:
`Overdose Prevention Strategies
`without Naloxone
`
`There are important ways you can
`integrate overdose prevention into
`your current work at little to no cost.
`Although all of these suggestions may
`not be relevant to your unique program
`structure, they are a great starting
`point to begin brainstorming ways that
`overdose prevention can fit into your
`program.
`
`The next section offers guidance
`for implementing some of these
`suggestions.
`
`Implementing Low-Cost Overdose Prevention Strategies
`
` (cid:133) Put up posters about preventing or responding to an overdose
`
` (cid:133) Provide educational materials (brochures, fact sheets) for program
`participants on overdose
`
` (cid:133) Develop a policy for responding to on-site overdose
`
` (cid:133) Train program staff and volunteers on overdose — including risk
`factors, signs and symptoms, and response (including rescue
`breathing and naloxone administration)
`
` (cid:133) Discuss overdose risks with participants and screen participants for
`higher risk
`
` (cid:133) Ask program participants if they have witnessed an overdose
`
` (cid:133) Ask program participants if they have survived an overdose
`
` (cid:133) Talk to program participants about the availability of naloxone
`
` (cid:133) Offer referrals to places where program participants can get naloxone
`
` (cid:133) Talk with program participants about what to do if they’re with
`someone who is overdosing
`
` (cid:133) Discuss or incorporate overdose prevention in groups
`
`
`Notes:
`
`Visit harmreduction.org to download this as a printable worksheet.
`
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`Integrate Overdose Prevention
`Messages as Standard Practice
`
`There are several practical, partici-
`pant-centered strategies that can be
`employed to assist staff in promot-
`ing overdose prevention messaging.
`Overdose prevention messages are
`relevant to anyone who uses drugs,
`whether they use prescription drugs
`or “street drugs.” These messages can
`easily be incorporated into various
`settings, including primary health care,
`mental health services, drug treatment
`programs, shelters, supportive housing
`or correctional settings.
`
`For example, staff can engage par-
`ticipants around overdose risk during
`informal conversations by asking
`if they plan to use alone or if they
`have friends that know they use. For
`participants who have recently been
`released from jail or come out of drug
`treatment, a conversation reminding
`them about the increased risk of over-
`dose can be lifesaving.
`
`More formally, staff can add
`questions about overdose risk to
`intake/assessment forms, health
`screenings or include overdose risk
`reduction as an integral component
`of treatment planning.
`
`Posting overdose messages on fliers or
`posters in the agency provides another
`way of engaging program participants
`around overdose and sends the mes-
`sage that staff is available to discuss
`overdose risk and response. Some
`examples of these types of messages
`
`can be found in the Appendix Overdose
`Prevention and Response Messages,
`online.
`
`The only costs associated with any of
`these strategies are staff time for train-
`ing and printing costs of any materials
`posted in the agencies.
`
`Develop an Onsite Overdose
`Response Policy
`
`A simple strategy for integrating over-
`dose prevention into your program is
`to develop a policy for responding to
`on-site overdose. Having such a policy
`in place is not only vital in the event of
`an overdose, but it has the additional
`benefits of getting agency staff or
`volunteers engaged in overdose
`prevention issues and sends a mes-
`sage to program participants that
`their lives and safety are valued. This
`strategy does not require a great deal
`of resources. The main cost involved
`in developing a policy is staff time for
`those involved in the policy develop-
`ment, as well as the time needed
`to train all staff on the emergency
`response plan once it is in place.
`
`In order to develop an overdose
`response plan for your agency, it is
`important to assess current circum-
`stances related to overdose. See box
`on page 15.
`
`These considerations are important
`to take into account when drafting
`an overdose response policy that is
`tailored to your agency. Some agen-
`cies may opt to incorporate naloxone
`
`14
`
`training into their protocol, others may
`rely on calling 911 and doing rescue
`breathing, while others may train staff
`to take all these measures. Examples
`of various overdose response policies
`can be found online in the Appendix,
`Sample Documents, online.
`
`Provide Overdose Response
`Training for Participants
`
`Overdose prevention and response
`education and training can be devel-
`oped for program participants even if
`a program is not yet equipped to dis-
`tribute naloxone. Some of the earliest
`overdose prevention efforts, such as
`distributing written materials, posting
`educational fliers and running groups
`about overdose, were initiated long
`before naloxone became available.
`
`Providing education about overdose
`risk, recognizing overdose, performing
`rescue breathing, and calling 911 can
`all be lifesaving interventions. These
`educational sessions can be incorpo-
`rated into existing group schedules
`or done one-on-one with participants.
`Session length can vary from ten to
`sixty minutes depending on the setting
`and trainee experience.
`
`Costs related to participant trainings
`vary depending on the different sup-
`plies you decide to incorporate into
`your workshop.
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`Basic costs for implementing overdose
`prevention training include:
`
`Develop an Overdose Response Plan
`
`(cid:114)(cid:1) Staff time: For outreach and to
`conduct or staff the training. See the
`Appendix, Training Materials, online
`for examples of training guides.
`(cid:114)(cid:1) Development/printing of materials
`and handouts: Educational materials
`can either be created in-house or
`there are numerous pamphlets and
`brochures available from other harm
`reduction organizations. See the
`Appendix, Overdose Prevention and
`Response Messages, online.
`
`
`Optional costs may also include:
`
`(cid:114)(cid:1) Rescue breathing dummies
`(approximately $70): A great training
`tool for practicing rescue breathing.
`(cid:114)(cid:1) CPR mouth shields (approximately
`$180 for a box of 250): Great for both
`training and incentives. See the
`Appendix, Naloxone Kit Materials,
`online for more details.
`
` (cid:133) Has overdose already occurred in your agency? If so, how was it
`handled? What worked well and what needs improvement?
`
` (cid:133) Are there locations within the agency that may present heightened
`overdose risks or complicate overdose response (such as bathrooms
`that lock or private rooms in Single Resident Occupancy hotels)?
`
` (cid:133) Does your agency have outreach staff or volunteers who work with
`people off-site, in the street or on home visits? What is the protocol if
`they witness an off-site overdose while working?
`
` (cid:133) Does an existing overdose response policy need to be evaluated or
`updated?
`
` (cid:133) Does your agency have staff on-site with medical and/or CPR training?
`
`Visit harmreduction.org to download this as a printable worksheet.
`
`15
`
`Opiant Exhibit 2187
`Nalox-1 Pharmaceuticals, LLC v. Opiant Pharmaceuticals, Inc.
`IPR2019-00688
`Page 15
`
`

`

`CASE STUDY
`
`Harm Reduction Action Center
`Denver, Colorado
`
`Harm Reduction Action Center finds
`creative ways to provide overdose
`prevention services despite their lack
`of access to naloxone.
`
`Since 2002, the Harm Reduction Action
`Center (HRAC) has been the only Colorado
`public health agency providing specific
`health information and holistic services
`to injection drug users and their sexual
`partners. The mission of HRAC is to educate,
`empower, and advocate for the health and
`dignity of Metro-Denver’s injection drug
`users and affected partners, in accordance
`with harm reduction principles. Guided
`by the principles of compassion, mutual
`respect and evidence-based solutions, HRAC
`seeks not only to meet immediate needs
`but to impart skills, education and behaviors
`needed to maintain personal health, reduce
`the harmful effects of marginalized life-
`styles, and reduce injection-impacted health
`risks for the larger public.
`
`According to the Colorado Department of
`Public Health and Environment, overdoses
`in Colorado have tripled in the last 10 years.
`Denver has been experiencing especially
`frequent fatal overdoses, with 8 fatal
`overdoses in one 6 week period on Denver’s
`Capitol Hill. Unfortunately, the overdose
`
`memorial in HRAC’s front room (where we
`put framed pictures or handwritten names
`of program participants that have fatally
`overdosed) has grown so much in the last
`couple of years that we’ve had to expand the
`memorial.
`
`It is very frustrating that we don’t have
`access to naloxone for our staff or program
`participants and their drug/social net-
`works. As of 2012, we have been unable to
`find a prescribing physician to help facilitate
`a take-home naloxone program. We have
`approached several doctors and have been
`met with resistance and a belief that provid-
`ing take-home naloxone is illegal and we
`will get in a lot of trouble for doing it. We are
`continuing to approach different doctors to
`educate them and discuss the possibility of
`starting a take-home naloxone program. It
`is slow going in Colorado. Syringe exchange
`programs were only made legal in 2010, with
`legal syringe exchange beginning in Denver
`in February 2012. 
`
`Until we can start a take-home naloxone
`program, the Harm Reduction Action
`Center provides overdose prevention
`messaging in two of our health educa-
`tion classes (Break the Cycle and STRIVE)
`along with quarterly overdose prevention
`trainings. We teach folks how to: identify an
`overdose, call 911 without explicitly telling
`the operator that it is a drug overdose (an
`effort to keep law enforcement away), per-
`form rescue breathing, and keep everyone
`
`calm. Also, our overdose messaging dispels
`common myths such as putting ice up
`someone’s ass, shooting someone up with
`milk or salt water, and other street myths.
`HRAC participants consistently ask for
`one-on-one consultations to cope with past
`overdose or will come to our agency first
`thing on the morning after an overdose. We
`take these opportunities to listen and offer
`encouragement for efforts taken during
`such a stressful time. 
`
`We honor August 31, International Overdose
`Awareness Day by organizing events in
`downtown Denver to speak about overdose
`and the stigma associated with drug use
`and overdose. Many mothers come up to
`us and cry; they have never been able to
`properly grieve for their child since fatal
`overdose can be stigmatizing for the entire
`family. In the event of a fatal overdose of
`a program participant, HRAC requests an
`autopsy from the Denver County Coroner
`and provides a memorial at our next all-
`IDU Advisory Committee meeting (which
`meets the 3rd Friday of every month). Harm
`Reduction Action Center looks forward to
`the day when we never have to add another
`person to our overdose memorial.
`
`Program update! As of Spring 2012, HRAC
`found a physician willing to prescribe nal-
`oxone for their program and have started
`providing naloxone distribution at their
`sites. (cid:132)
`
`16 CASE STUDY
`
`Opiant Exhibit 2187
`Nalox-1 Pharmaceuticals, LLC v. Opiant Pharmaceuticals, Inc.
`IPR2019-00688
`Page 16
`
`

`

`Module 3:
`Take-Home Naloxone Program Development
`
`As of 2010, there were over 188 sites in
`15 US states and Washington DC where
`someone could obtain take-home
`naloxone. Most of these programs are
`run out of syringe access or other harm
`reduction programs, but take-home
`naloxone programs are expanding to
`physician’s offices, drug treatment pro-
`grams and hospital emergency rooms.
`
`Harm reduction programs were a logi-
`cal first home for take-home naloxone
`programs because they already work in
`close collaboration with people using
`drugs. Harm reduction programs have
`a direct source of knowledge from drug
`users who have overdosed or wit-
`nessed overdose, including insight into
`how first responders and emergency
`rooms are treating overdose victims
`and changing drug trends that impact
`overdose risk.
`
`It is also appropriate and necessary
`to implement take-home naloxone
`programs in a variety of other set-
`tings with access to individuals who
`are, or could be, at risk for overdose.
`Take-home naloxone programs are also
`invaluable for potential bystanders
`or witnesses to overdose, like family
`members or loved ones of people who
`use drugs.
`
`This section will outline important con-
`siderations when planning a take-home
`naloxone program including commu-
`nity engagement, legal considerations,
`the role of medical professionals and
`special considerations for implementa-
`tion within different venues.
`
`Community Assessment,
`Outreach and Engagement
`
`Engaging in a community planning
`process is an important step in creat-
`ing a take-home naloxone program.
`It is important to tailor your overdose
`prevention work to the community you
`work in and, whenever possible, gain
`community buy-in. One of the first
`and most important steps is to gather
`information about overdose in your
`community. See boxes on pages 20-21.
`
`Some communities are able to collect
`this information using formal sources,
`such as the Medical Examiner’s office,
`however in some communities it can be
`more difficult to get this information. It
`is helpful to tap into the knowledge of
`community members who are already
`somehow engaged with those most
`at risk of overdose, and also to bet-
`ter understand and assess what is
`currently known about local overdose
`trends.
`
`These groups may not only be inter-
`ested in supporting future work on
`overdose prevention, but they may
`also have valuable information about
`current and past overdose risks in the
`community. If you do not already work
`with drug users, familiarizing yourself
`with service providers who work with
`drug users can facilitate the linkage
`of your program to those most at risk
`for overdose. Reaching out to these
`stakeholders will help make your
`take-home naloxone programs more
`relevant and better integrated within
`the community.
`
`Reviewing Existing Data
`Gathering both qualitative and quan-
`titative data will be helpful in making
`a case for local take-home naloxone
`programs and will also help you target
`your services to those most at risk.
`Similar to the list of potential commu-
`nity stakeholders, possible sources of
`local data and information include the
`following:
`
`(cid:114)(cid:1) City and State Health Departments
`(cid:114)(cid:1) Community Needs Indexes (where
`applicable)
`(cid:114)(cid:1) Emergency Medical Services
`(Ambulance, Fire)
`(cid:114)(cid:1) State or City Offices of Vital Records
`(cid:114)(cid:1) Medical Examiner or Coroner’s Offices
`(cid:114)(cid:1) Local emergency rooms
`
`17
`
`Opiant Exhibit 21