As rates of substance use disorders rise across the U.S., post-overdose outreach programs have become an increasingly popular tool for engaging at-risk individuals. But as a relatively new concept, practices for documentation and measurement to this point have remained largely unrefined.
At the upcoming Rx Drug Abuse & Heroin Summit, Michele M. Farry, drug addiction and recovery team coordinator with the City of Northampton (Massachusetts) Health Department, Scott Formica, PhD, senior research scientist for Social Science Research and Evaluation in Burlington, Massachusetts, and J. Cherry Sullivan, program coordinator for the City of Northampton Health Department’s Hampshire HOPE, will highlight initiatives that have made progress toward developing formal data tracking systems for such interventions.
Ahead of the Rx Summit, Farry and Formica spoke with Addiction Professional about why post-overdose outreach programs are gaining popularity, the process of establishing best practices, and the right data points to start with.
Editor’s note: This interview has been edited for length and clarity.
Why are post-overdose outreach programs gaining popularity across the U.S.?
Formica: What we’re seeing is that since 2015, there has been almost a doubling in the number of these programs. While I don’t have a definitive answer on that, I think there are a couple things driving this. One, over the last five years and even within the last three in particular, there has been an increase in funding and support for these programs. … There has been more federal support for this. At the local level, there has been more support as well. As these programs are implemented in more municipalities, you have police chiefs, fire chiefs and EMS chiefs hearing about it within their networks. I think there is a lot of word-of-mouth momentum on this. It’s another thing agencies can add to their belt with public health and public safety beyond Narcan and business as usual. It’s something else they feel they can do.
Farry: In 2015, when we saw the rise in opioid overdose fatalities, there was a surge of local coalitions that became very mobilized to try to comprehensively understand and cohesively come together to address the challenges for the populations at risk in their communities. With those coalitions, we see a lot of people around the table and a lot of willingness to learn how to work together. For Hampshire HOPE, we had a lot of first responders and partners around the table who were particularly seeking a model to come together to approach this. There are very nuanced iterations of what post-overdose interventions look like. In some communities, it’s being executed out of emergency department grant-funded programs and things that are more looking to introduce medication for opioid use disorder or medication-assisted therapies as part of different programs. Although there are lots of different iterations, look and feel, and home bases for these programs, overall there is a feeling of a need to respond and act. As we see communities coming together looking for opportunities to find multi-sector approaches, we’re hopeful that presentations like ours can start to produce some measures and consistency in evaluation. As much as the sense of urgency to act has become common, we’re now looking to create more fidelity and awareness of unintended consequences and thinking through what the data is driving.
Is everyone kind of figuring it out as they go with regards to best practices right now?
Farry: There are a lot of good intentions, warm hearts and best efforts. There are not a lot of standards of practice or evidence-based practice research. We have very little to work off of because we are talking about a rapid time frame. Sometimes, this kind of research can take a couple decades to look and comprehensively break down, and all of the nuances and risk factors for what people’s predispositions are, as well as what their outcomes might be. With all of these moving parts and systems, some will trickle down to community-level applications for best practices, at least initially. Some might be best practices within the fields and sectors that are the initiators of this work. But overall, it’s something we’re trying to catch up on as fast as we can to get more baseline in the way people are collecting data to measure these programs, as well as looking at precursors and outcomes. We do know that with the biggest hearts and best intentions can be significant unintended consequences. We want to make sure we’re providing on a national level information back to leaders who are funding these grants to try to look for best practices and fidelity and mitigating any harm that could come from these good-natured efforts.
What are some specific data points that organizers should concentrate on? Where do we begin?
Formica: For many of these programs, there is a continuum when you’re talking about best practices, evidence or data. You have the lived experience, word-of-mouth, wisdom of practice angle, which we did know a little about. Then, it’s evolving into is this a database guideline or an expert-informed guideline? For a lot of this, the practice has outpaced the science. We’ll be playing catchup for 3, 5 or maybe even 10 years. Related to that, there is almost a need up front to collect data that are going to help inform what the program is and what the program looks like. This can go back to the logic model and the strategic planning phase: What is our program philosophy? What are the goals and objectives of our program? Does everyone at the table even agree on goals and objectives and what the outcomes could be? I think that piece, more than anything else, defines data elements you should be focusing on, particularly in those early months. It’s easy to say we’re going to track the number of referrals to treatment agencies or successful linkages to a system of care. That might not be the ultimate outcome for some of these programs. Some are more on the harm reduction side where you want to focus on incremental changes, the tiny steps of moving someone along the continuum.
In the programs we work with and the programs we evaluate, we want to talk about how many outreach visits are the teams going on, who’s taking part in those visits, what does the team look like, how many individuals are the teams encountering? Are the teams just encountering and interacting with overdose survivors, or are they broadening this to working with social network members? You can organize it by a person perspective, an outreach perspective and an outcomes perspective, thinking through the different levels. How often am I going out? What am I doing? What services are we referring people to the most?
The main point I’d want to come back to is that at the outset, it’s more of a process evaluation where you’re just trying to figure out what are we doing before we start to think about outcomes.
Farra: For people who are in leadership roles, starting to design these programs, or taking a program that is providing some of these services and then coming back to figuring out what the data elements could be broken out to be, it’s really important to understand the participant you intend to reach out to and what the objectives are that your program is offering them. By identifying those data forms, a lesson we learned was that we had every intention of connecting with people who were using drugs, may have experienced an overdose or were at risk of an overdose, and quickly found in the data forms our team was using that 6 out of 10 participants that were looking for support in our program happened to be family members or social system network individuals. We were able to quickly refine and separate those types of data tracks and data element forms because obviously there would be different services and offerings in the continuum of care for a family member versus potentially an individual still using drugs or is at risk for an overdose.
So, very much data strategies required by your grant funder might be demographics, basic system level information, information on whether the individual has employment, housing, transportation or other related need. Beyond that, we need to think about what our systems can offer reliably and how we can measure what could be accomplished by our teams and also attainable by the person for long-term outcomes. Some of the more templated versions of data gathering forms have to be nuanced and refined to that local community. There is not a one size fits all with this kind of data measurement. It’s not going to be consistent within a county what health-based systems or harm reduction-based systems are available versus the other side of the county. We have to do a little bit of selective data necessities based on the contextual community and population you are serving.
Formica: One thing we also talk about a lot is the timing of data collection with these programs. And the reason I say that is in contrast to interventions or services where someone is going to a service—a detox center or treatment facility—we always recognize this as being quite a bit different in that the initial engagement point many times is the provider or team going to the person, to their home or where an overdose has happened. It’s a little different when we think about what data can and should we be collecting when someone’s coming to me and I can say, ‘Let me do any intake. What’s your name, date of birth, social security?’ versus two to three people showing up on your doorstep and immediately saying, ‘What’s your name? How old are you? What’s your social security number?’ So, really thinking through at what point in that process should teams be collecting information and what questions they should ask. ... I would say for a lot of these cases, we have less data than we’d love, but there’s a reason for that. Based on processes in place, it might not be appropriate to go all the way down the rabbit hole on some data points out of the gate.