In this chapter, the committee presents its findings related to the activities conducted by the OD Treatment Access grantees and the outcomes of these activities. The findings are organized by the framework developed by the committee, as described in Chapter 2, including accomplishments in grantee and partner activities and structural and environmental change, barriers to those efforts, and discussion of individual- and community-level outcomes. Before the findings are presented, a recap of the program purpose and information sources reviewed by the committee is presented. Committee conclusions are presented in Chapter 7.
Title I, Prevention and Education, Section 107: Improving Access to Overdose Treatment Program (OD Treatment Access) of the Comprehensive Addiction and Recovery Act allows the U.S. Department of Health and Human Services (HHS) to award grants to eligible entities to expand access to opioid overdose reversal drugs or devices.
The OD Treatment Access awardees include federally qualified health centers (FQHCs), opioid treatment programs, and qualified practitioners with a waiver to prescribe buprenorphine. One grant was awarded in fiscal year (FY) 2017, and an additional five were awarded in FY2018 (SAMHSA 2017f, 2018e).1 Grantees may receive funding for up to 5 years (SAMHSA, 2017d). A complete list of grantees can be found in Appendix A.
The grantees and their partners endeavored to develop best practices for prescribing and co-prescribing opioid reversal agents. After developing these best practices, the grantees were expected to train other prescribers in key community sectors as well as individuals who support persons at high risk for overdose.2
As discussed in Chapter 2, the committee reviewed information from two different sources. The committee received anonymized data from SAMHSA submitted by grantees through the Division of State Programs Management Reporting Tool (DSP-MRT) reporting system.3 Most of the information provided comprised the free text submission in response to specific modules from the DSP-MRT. As described in Chapter 2, the committee sampled the complete set of entries and can be found in the online appendix [O1 a-c]. Entries from which those sampled items were chosen are also found in the online appendix [O2, O4, O5, O6, O8, O10, O12]. Aggregate data for some components of the DSP-MRT were provided. Responses from five of six grantees to the supplemental DSP-MRT were provided, and the committee reviewed the final submission from each of those grantees [O13–17].4 Due to the nature of the reporting, it was not always possible to determine whether the activities and outcomes were achieved by the grantees or by their partners.
To supplement the information received from the Substance Abuse and Mental Health Services Administration (SAMHSA), the committee subcontracted with NORC to conduct interviews with a sample of grantees. The report is reprinted in its entirety in Appendix B, and the limitations are discussed in greater depth there.
In this chapter, the committee has also noted relevant literature about the effectiveness of interventions similar to those grantees implemented. However, because the committee often did not have enough information about grantee contexts, it also cannot directly compare grantee efforts to this outside literature or directly extrapolate inferences about grantee effec-
3 All information supplied by SAMHSA is available on request through the National Academies Public Access File, see https://www.nationalacademies.org/our-work/review-of-specificprograms-in-the-comprehensive-addiction-and-recovery-act (accessed March 6, 2023). Information used directly in the report are publicly available in an online appendix on the National Academies Press website as “additional resources” to the published report: https://nap.edu/26831 (accessed March 9, 2023). Specific citations refer to the source of the material and indicate the program and Excel citation, for example, (OD treatment access [O], workbook , and worksheet [a]).
4 These files are Word documents, also found in the online appendix.
tiveness. Nevertheless, it notes some instances in which grantee plans were rooted in interventions that have potential to be effective.
This section begins with describing accomplishments reported by grantees in terms of their activities and those of their partners [O1b and c]. Barriers are described in a subsequent section. The primary activities reported by the grantees related to training. However, the grantees also undertook multiple changes in their systems that are likely to reduce the risk of overdose; these are addressed in a separate section below. The most impressive accomplishments were those activities that went beyond best practices for use of opioid reversal agents and affected treatment.
The grantees also faced challenges in their activities that are identified in a separate section below. These ranged from the COVID-19 pandemic to resource issues to difficulties with partners.
It was often difficult to determine which accomplishments were specific to the grantee versus those that were done by the partners.5 Thus, this report outlines the different areas of accomplishment done over the course of the grant by partners and grantees.
Creation of New Training Materials
One of the primary goals of this project, as laid out in SAMHSA’s Funding Opportunity Announcements, was creating training materials for partner sites to use for opioid reversal training. Generally, increasing the number of individuals trained to administer naloxone increases the likelihood of naloxone availability and use. Grantees/partners reported developing several different training modules specialized for unique settings. For example, one grantee/partner reported training tailored to schools and local colleges; another grantee reported developing specialized training for FQHC and emergency room settings; yet another grantee adapted training materials for jail inmates and staff. Another grantee reported adapting training materials to a Spanish language version to reach non-English speaking populations. Finally, one grantee reported developing/awarding continuing medical education (CME) for providers who attended training. Material from SAMHSA indicates that grantees trained more than 5,000 physicians, physician assistants, nurse practitioners, pharmacists, and others on prescribing naloxone for emergency treatment of known or suspected opioid overdose [O3a].
5 References to grantee or partner should be understood as interchangeable, as it was often difficult to distinguish the actor for some of the activities described.
Development of Assessment Materials and Targeting High-Risk Areas
Grantees developed opioid overdose knowledge and surveys to assess the impact and change in knowledge associated with training. Further, one grantee mentioned development of new quality improvement efforts to ensure maximal impact of its naloxone distribution program. Additional assessments included determining highest risk areas for overdose and targeting intervention efforts in these high-risk settings. Finally, grantees mentioned trying to assure consistency of naloxone distribution across various health centers.
Many grantees reported establishing or strengthening partnerships across many different settings and organizations. For example, several grantees talked about establishing partnerships at local substance use disorder treatment centers. Other grantees discussed partnering with traditional medical settings like FQHCs and emergency rooms. One grantee mentioned outreach and partnerships at local jails, while another grantee/partner mentioned developing a partnership with the drug and mental health courts. One grantee/partner felt that there were generally adequate resources to support the development of partnerships. In particular, one grantee mentioned being able to strengthen existing partnerships with organizations such as the Office of Behavioral Health, Planned Parenthood, emergency medical services, and district agencies. Other examples of partnerships included development of police “ride alongs” for treatment staff and strategic partnerships with the sheriff’s office.
Several grantees/partners reported that grant funding enabled them to add specific staff positions to aid in the development of partnerships, training activities, or distribution efforts. For example, several partners reported adding therapists, case managers, and other staff to their partner organizations to facilitate training and distribution of opioid overdose reversal interventions. Another grantee reported using patient navigators to engage patients receiving medications for opioid use disorder (MOUD) but having difficulty maintaining abstinence. Another example of adding personnel included engaging medical and social work students in the grant activities. Other added personnel included a staff member to the drug court team. Finally, one partner reported designating a specific staff member to be the point of contact with law enforcement to facilitate referral for treatment.
Expansion of Overdose Prevention Activities
While grantees/partners reported universally training for opioid overdose reversal using naloxone kits, additional opioid overdose prevention activities were also mentioned. For example, one grantee/partner mentioned buying and distributing fentanyl test strips, which have proven to be effective in reducing overdose incidence. As stated in the second report in this series,
Given the prevalence of potent illicitly manufactured synthetic opioids, routine distribution and utilization of rapid fentanyl test strips as a part of syringe services programs may lead to behavior changes in injecting6 and an overall lower overdose risk (Karamouzian et al., 2018; Krieger et al., 2018; Peiper et al., 2019). This may be an especially important intervention given evidence that naloxone may not be as effective in preventing overdose deaths by fentanyl and its analogs. (Torralva and Janowsky, 2019)
Other grantees/partners mentioned expansion of MOUD and increasing linkage to help patients access MOUD and other treatment services; MOUD has been shown to be both effective and cost-effective in combat-ting opioid use disorder (Fairley et al., 2021; NASEM, 2019). Similarly, another grantee/partner mentioned expanding buprenorphine initiation in the emergency room setting. Another grantee/partner reported developing protocols to allow for continuation of MOUD among individuals who become incarcerated, which could help address a notable gap in access for this population (NASEM, 2019).
In addition to the above activities, grantees and their partners carried out several activities that were intended to change the structure of systems and improve the environment for the delivery of overdose and treatment services. As such, these changes have potential to reduce the risk of overdose in the future.
Creation of Toolkits and Presentations
As a primary aim of the grant, grantees and/or partners developed training programs regarding best practices related to opioid reversal agents. The COVID-19 pandemic resulted in an evolution of many of these pro-
6 For example, when fentanyl is detected, using less, using slower, using with someone else around.
grams from live offerings to video conference and asynchronous programs. Though revisions will be required as care evolves, the grantees now have a basic educational template for enduring use in ongoing educational and training activities. Many of these were based on SAMHSA’s overdose reversal toolkit, which is evidence based.7
Establishment and Strengthening of Partnerships
The establishment of new and strengthening of existing partnerships is another key structural and environmental change in the communities served by the grantees. These partnerships can help to increase communication among agencies and may result in permanent changes in protocols and processes related to the care of people with opioid use disorder. Examples of specific structural and environmental changes, by way of partnerships, reported by grantees include addition of a case worker to the police department, adding a member to the drug court team, engaging the assistance of medical and social work students, designation of points of contact with law enforcement, and creation of a new Overdose Treatment Access Collaborative to address critical service gaps.
While one grantee reported developing a pharmacy “detailing” program, another reported building a cross-systems coordination among pharmacies, medical providers, behavioral health, community service entities, hospitals, emergency departments, and justice entities.
New Protocols, Processes, and Services
In their reports, grantees highlighted efforts to improve the services they and their partners provide in the long run. For example, grantees undertook a variety of activities to change systems to encourage co-prescribing of naloxone with prescription opioids and buprenorphine/naloxone. This is an increasingly common intervention for reducing overdose, so efforts to increase and spread this practice could result in worthwhile impacts on the community. One grantee reported the development of a co-prescribing toolkit.
Another set of structural/environmental changes involved law enforcement and correctional services. New methods for coordination with law enforcement directed the police transport of people with SUD to treatment services, which is intended to avoid arrest and incarceration. Another implemented changes focused on continuity of care with corrections facilities. This included development of protocols to continue medication for opioid
7 This toolkit has been revised several times over the course of the grantees’ funding periods. The current version can be found at https://store.samhsa.gov/sites/default/files/d7/priv/sma18-4742.pdf (accessed January 19, 2023).
use disorder in incarcerated individuals as well as using care navigators to help assure continuation of medication upon release. One grantee reported that it developed new protocols to better link overdose survivors to treatment and social work services to support recovery.
Changes in Informational Technology Systems
The grants also enabled changes in informational technology to assist grantees and their partners, which may carry benefits beyond the grant period. One grantee reported changing electronic health record systems to include opioid overdose history in the patient’s social history. Another developed methods to collect overdose statistics from multiple counties to direct future efforts. Several grantees used survey methodology to evaluate the outcomes of their training programs. SAMHSA did not share all of these results with the committee.
Other Innovative Accomplishments
Among the more creative of the accomplishments was the development by a grantee of an Overdose Risk Registry embedded in the electronic health record. This registry used patient-specific factors to determine patients with the highest risk. Specialized care navigators then directed outreach efforts to those patients identified by the registry. They were offered naloxone training, overdose reversal kits, assistance in scheduling appointments, and other resources that could be effective.
One grantee reported promotion of a “24/7” addiction medicine hotline and expansion of an existing addiction medicine program.
While all the grantees developed, revised, and implemented new education programs, the pandemic forced changes in the model of presentation. Videoconferencing technology was implemented by many programs.
The grantees faced multiple challenges in the development and implementation of their projects, which impacted grantee and partner activities, as well as efforts to create structural change. Source material for this section can be found in the online appendix [O1a and b].
The most cited barrier was the COVID-19 pandemic. Much of grantees’ implementation periods have overlapped with the pandemic: the FY2017
cohort grantees were implementing their programs through September 29, 2022, and the work of the FY2018 grantees is still ongoing, through September 30, 2023. COVID-19 not only impacted live training programs, but also consumed the attention of many health care providers. The most common barrier was difficulty in engaging some of the community organizations in partnership. Grantees reported that in some cases, it was difficult to engage hospitals, emergency departments, pharmacies, and providers. Lack of attendance at meetings was cited as a concern. Certainly, all of these entities had a primary focus on the pandemic for an extended time. Finding community partners to provide MOUD was an additional barrier.
Design of Training Activities
The design of training activities was a challenge for some grantees. The committee noted that it was not clear how many grantees, if any, included representatives of the intended audiences in the development of the training to understand the needs and practice of potential partners and specific audiences, which could have ameliorated some of these challenges. Some that undertook a one-size-fits-all approach had to back-track and develop different training for different audiences. Some discovered that the duration of their training sessions was too long to accommodate the schedules of busy health professionals. Others reported that not offering continuing education credits for some professionals was an issue. Finally, there were reports that many health professionals and facilities had already received training on opioid issues and were not receptive to additional training.
Multiple grantees reported resource issues. They cited inadequate staffing as many staff members involved in the grants still maintained significant caseloads, making it difficult to engage them on these efforts. Some stated that there was no backup for staff that were on leave. In particular, some reported difficulty recruiting therapists. As noted previously, such staffing issues are not unique to this grant program. Several grantees were concerned about resources for purchasing naloxone in the future.
Grantees were also concerned about issues within their own organizations. They cited challenges such as inadequate data collection tools, inadequate data on specific drugs, maternal and child health and child abuse, and lack of training to appropriately support some communities facing the highest degrees of health inequities.
Source files from SAMHSA indicate that among all six grantees 992 individuals were connected to treatment as a result of this program. Of that total, 592 were reported to have initiated treatment [O3a]. More than 2,000 naloxone kits were distributed. It is difficult to know whether these numbers represent the total or include a reporting bias. It is also difficult to know whether this represents a significant contribution to overdose reversals and treatment for the populations of interest to the grantees. The committee did not have adequate information to compare this to population-level characteristics or outcomes that would enable it to determine this. Additionally, it is unclear whether all instances were documented.
With the information provided by SAMHSA, the committee was not able to quantify the impact of grantee actions on the community. That said, as the references to external literature suggest, the committee has reason to believe that the actions grantees and their partners took could contribute to positive population outcomes in the long run, though there is not enough information on implementation to determine whether this was the case. The OD Treatment Access grantees provided training regarding overdose and naloxone use for health professionals and members of the community [O1b and c]. The partnerships may have helped reduce stigma among some health professionals. The system, protocol, and process changes can all facilitate greater access to treatment. Sustainability of these projects would be important to ensure that what is learned and developed continues to provide community benefits.
Overall, several grantees and partners developed significant programs that increased training and distribution of opioid reversal agents. These trainings spanned a diverse range of settings from traditional substance use disorder treatment centers, to traditional medical settings (e.g., FQHCs, emergency departments) to more unreached settings such as colleges and prison/correctional settings. Training activities sometimes required revision. Some grantees faced challenges enlisting partners. This may have been exacerbated by inadequate knowledge concerning the needs, prior training, and/or practice setting of intended training recipients and failure to include them in planning.
In addition to the mandate to increase trainings and distribution of naloxone, several grantees and partners expanded in other areas that were
impactful for reducing opioid overdoses, distributing fentanyl strips and continuing or expanding MOUD into high-risk settings (e.g., correctional facilities). These efforts are laudable as they have also been shown to be important tools for reducing overdoses. However, barriers to implementation of the training and distribution of opioid reversal interventions were identified including difficulty engaging community partners, data collection challenges, staffing shortages, sustainability, and the impact of the COVID-19 epidemic.