Barriers to and recommendations for take-home naloxone distribution: perspectives from opioid treatment programs in New Mexico

Salvador et al. Harm Reduction Journal (2020) 17:31 https://doi.org/10.1186/s12954-020-00375-2 RESEARCH Open Access Barriers to and recommendations for takehome naloxone distribution: perspectives from opioid treatment programs in New Mexico Julie G. Salvador1* , Andrew L. Sussman2, Mikiko Y. Takeda3, William G. Katzman4, Monica Moya Balasch5 and Joanna G. Katzman5 Abstract Background: Naloxone is a safe and effective medication to help reverse opioid overdose. Providing take-home naloxone to patients in opioid treatment settings is a critical step to reducing opioid overdose deaths. In New Mexico, a US state with one of the highest rates of opioid overdose deaths, legislation was passed in 2017 (House Bill 370) to support take-home naloxone, and followed by naloxone training of Opioid Treatment Program staff to increase distribution. Methods: Naloxone training was offered to all New Mexico Opioid Treatment Programs along with a baseline survey to assess current practices and barriers to take-home naloxone distribution. Focus groups were conducted approximately 1 year post-training with staff at a subset of the trained Opioid Treatment Programs to assess the impact of the legislation and training provided. Results: Baseline survey results show most Opioid Treatment Program staff were unfamiliar with House Bill 370, reported conflicting understandings of their agency’s current take-home naloxone practices, and reported a number of barriers at the patient, agency, and policy level. Follow-up focus groups revealed support for House Bill 370 but persistent barriers to its implementation at the patient, agency, and policy level including patient receptivity, cost of naloxone, staff time, and prohibitive pharmacy board regulations. Conclusions: In spite of targeted legislation and training, provision of take-home naloxone at remained low. This is alarming given the need for this lifesaving medication among the Opioid Treatment Program patient population, and high opioid death rate in New Mexico. Locally, important next steps include clarifying regulatory guidelines and supporting policy/billing changes to offset costs to Opioid Treatment Programs. Globally, additional research is needed to identify the prevalence of take-home naloxone distribution in similar settings, common barriers, and best practices that can be shared to increase access to this vital lifesaving medication in this critical context. Keywords: Take-home naloxone, Drug policy, Opioid overdose, Opioid treatment programs * Correspondence: 1 Department of Psychiatry and Behavioral Sciences, University of New Mexico School of Medicine, MSC09 5030 1UNM, Albuquerque, NM 87131-0001, USA Full list of author information is available at the end of the article © The Author(s). 2020 Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Salvador et al. Harm Reduction Journal (2020) 17:31 Introduction The opioid crisis is a public health emergency worldwide. It is estimated that roughly 27 million people globally have an opioid use disorder (World Health Organization, 2018), with approximately 3 million of those in the USA [1]. In the USA, more than 130 Americans die every day due to unintentional opioid overdose deaths [2]. Opioids accounted for 69.5% of all drug overdose deaths in 2018 [3]. Efforts to address this crisis include expanding access to medications to treat opioid use disorder—including methadone, buprenorphine, and naltrexone—in combination with psychosocial supports. In spite of the research evidence supporting the effectiveness of these medications, there remain barriers to their uptake among behavioral health and primary care settings [4]. Therefore, for many people, treatment for opioid use disorder remains difficult to obtain and access is even more challenging in rural areas [5, 6]. Given this lack of comprehensive treatment, a key harm reduction strategy to reducing opioid overdose deaths is increasing access to naloxone among persons likely to either experience or witness an opioid overdose. Naloxone is a safe and effective medication that can be easily administered to anyone who is experiencing an opioid overdose and many states have passed laws to help expand access and use of naloxone among laypersons [7]. Methods of naloxone administration include a simple auto injector format (similar in function to an Epi pen for allergic reactions) and a nasal spray. There is strong evidence to support take-home naloxone (THN) in terms of reduction in overdose mortality deaths [8] and the real-world use of naloxone for overdose reversal following adequate training [9, 10]. Federal funding for states to address the opioid use disorder (OUD) epidemic has included a heavy focus on making naloxone and the simple training in its use easily available nationwide. However, access to THN is currently insufficient to address the opioid overdose crisis in the USA [11]. The World Health Organization (WHO) recommends that naloxone be made available to persons likely to witness an opioid overdose, which includes persons at risk of an opioid overdose, their friends, and families [12, 13]. Recent research has demonstrated that providing naloxone to patients in an opioid treatment setting resulted in their use of naloxone to reverse overdose in their community. In fact, nearly 20% of patients provided naloxone used it to reverse an overdose, some even conducting multiple reversals [14]. New Mexico, the setting for the present study, is the fifth largest US state, is predominantly rural and frontier, and has drug overdose death rates consistently higher than the national average [15]. In 2017, New Mexico approved House Bill 370 Opioid Overdose Education to help increase access to naloxone within the state’s Page 2 of 8 Opioid Treatment Programs (OTPs) [16]. In New Mexico, OTPs are often referred to as “methadone clinics” but many also provide other medications and treatments for opioid use disorder and substance use disorder (...truncated)