6
FR-CARA Findings
In this chapter, the committee presents its findings related to the activities conducted by the First Responder Training (FR-CARA) grantees and the outcomes of these activities. The findings are organized by the framework developed by the committee, as described in Chapter 2, including grantee and partner activities, outcomes at the individual and community levels, and environmental and structural change efforts. The program purpose and the information sources reviewed by the committee are summarized below. Committee conclusions are presented in Chapter 7.
PROGRAM PURPOSE
Title II, Law Enforcement and Treatment, Section 202: First Responder (FR) Training of the Comprehensive Addiction and Recovery Act (CARA) authorizes the U.S. Department of Health and Human Services (HHS) to make grants to state, local, and tribal law enforcement agencies for training in the emergency use of naloxone (or other U.S. Food and Drug Administration [FDA]-approved devices) and naloxone purchases.
The Substance Abuse and Mental Health Services Administration’s (SAMHSA’s) Center for Substance Abuse Prevention (CSAP) began accepting applications for the FR-CARA program in fiscal year (FY) 2017. FR-CARA aims to encourage first responders and other key members of the community (see Box 1-2 in Chapter 1 for definitions of these entities) to administer drugs and devices for treating opioid overdose when necessary and to promote treatment for opioid use disorder (OUD). SAMHSA funded the first cohort of 21 projects in FY2017 (SAMHSA, 2017e); an additional 27 projects were funded
in FY2018 (SAMHSA, 2018d).1 The 48 total projects comprise a mix of recipient organizations: Native American tribes; emergency medical response service organizations; state, county, and local health departments; medical centers; health and wellness centers; municipalities; substance use disorder treatment facilities; and a university. Grantees may receive funding for up to 4 years (SAMHSA, 2017c). A complete list of grantees can be found in Appendix A.2
INFORMATION SOURCES AND LIMITATIONS
As discussed in Chapter 2, the committee reviewed information from two different sources.3 The committee received anonymized data from SAMHSA submitted by grantees through the Division of State Programs Management Reporting Tool (DSP-MRT) system. Most of the information provided comprised the anonymized free text submission in response to specific modules from the DSP-MRT and its FR-CARA supplement. Aggregate quantitative data for some components of the DSP-MRT were provided. As described in Chapter 2, the committee sampled the submissions and reviewed 491 free text entries [F1a–i].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.
In order to supplement the information received from 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. The NORC report combined findings from FR-CARA grantees with those from the Improving Access to Overdose Treatment (OD Treatment Access) grantees; as such, it is sometimes difficult to attribute comments to one program or the other.
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-
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1 See Box A-4 in Appendix A for a complete list of FR-CARA grantees.
2 Text in this section is reprinted from the second report in this series (NASEM, 2021).
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). Citations such as [F18c] refer to FR-CARA (F), workbook number (18), and worksheet (c).
4 The complete set of entries from which the committee sampled for the analysis in this chapter can be found in the online appendix. See F2, 4, 5, 6, 8, 10, 12.
tiveness. Nevertheless, it notes some instances in which grantee plans were rooted in interventions that have potential to be effective.
FINDINGS: GRANTEE AND PARTNER ACTIVITIES
FR-CARA grantee reports included many accomplishments and challenges, but no single issue was mentioned uniformly across grantees, which is perhaps unsurprising given the diversity of grantees. Most FR-CARA grantee reports included general statements on results and completion of activities, but details about accomplishments and challenges were rarely included in the reports. It is possible that more activities, accomplishments, and challenges were identified by grantees but grant reports did not capture these activities and results.
Accomplishments
The funding provided by the FR-CARA program allowed grantees to conduct needs assessments to inform project development and fill critical gaps in expertise to carry out their projects (e.g., hiring data analysts with expertise in substance use disorders). Some FR-CARA grantees identified the importance of training opioid treatment providers on how to use naloxone. These needs assessments used many different sources of data (e.g., surveys, overdose data), and many of them were conducted in close collaboration with law enforcement and emergency medical services (EMS).
Naloxone Distribution and Training
SAMHSA data suggest that grantee partners distributed almost 30,000 naloxone kits [F18c] and administered almost 95,000 doses [F18d], although that number can include doses provided by the grant or through other funds.
The NORC report (Appendix B) highlights how CARA funds allowed some grantees to perform more naloxone distribution and training to laypersons and first responders, strategies that have been proven to be both effective and cost-effective in preventing overdose in a variety of settings (CDC, 2018b; Chao and Loshak, 2019; Chimbar and Moleta, 2018; Coffin and Sullivan, 2013; McClellan et al., 2018; Naumann et al., 2019; NIDA, 2017; Townsend et al., 2020). Some grantees noted that because their organizations were already well established in their communities and/or were part of a strong network, they were able to launch and run their projects relatively fast and, as a result, serve more clients.
Also, we’ve been able to do a lot more work in terms of expanding and increasing the amount of naloxone overdose education and distribution . . . The
grant funding has been fantastic for that . . . So, before we would get a lot of requests to do trainings, which we did as best we could, go to a program and we train their staff on how to use naloxone and respond. But it was sort of like a one and done, and a lot of them actually kept coming back to us months later, and say ‘we have new staff can you do this again?’ And now we’re able to offer this training, but then also help them become their own program and have capacity to distribute naloxone. So, then it’s not just a one and done. – ID 1007 (CSAP)
Some FR-CARA grantees mentioned that they were able to extend their use of funds beyond what they had originally proposed with approval from their SAMHSA Government Program Officer. As a result, these grantees were able to increase their capacity to serve more clients. Examples of these efforts include grantees being able to expand the use of funds to include first responders at different agencies within the same region, receiving approval to expand the use of funds to serve clients dealing with non-opioid substance abuse, and supporting mobile response efforts in rural areas.
The committee noted reports from grantees on a wide variety of activities central to the grant purposes, such as naloxone training and distribution and development of EMS training curriculum. One grantee extended its training to include performing the evidence-based Screening, Brief Intervention, and Referral to Treatment (Babor et al., 2007) in a prehospital setting (SBIRT-EMS). The grantee provided training for 28 EMS professionals from 8 agencies to determine practicality, feasibility, and effectiveness of SBIRT-EMS in prehospital settings.
Some grantees reported using pre- and post-survey results regarding training about stigma and overdose training, and using pre- and post-survey results and focus groups to understand overdose reversals and improve training. One grantee noted that 13 participants filled out the class evaluation, and all participants (100%) stated that they agreed or strongly agreed with the fact that they learned something new during the naloxone and overdose training. Similarly, all participants (100%) stated that they agreed or strongly agreed with the fact that they feel more confident in responding to an overdose. For the post-training assessment, all 13 participants (100%) scored an 80 percent or better, with an average score of 96 percent.
New Tools
Some grantees reported developing new tools, such as a grief toolkit for families: “We worked with a regional expert on bereavement to develop a toolbox and future training on supporting families once a loved one has died from overdose.” Another grantee noted opening of a 24/7 opioid assistance and referral hotline. Another grantee noted making tools available
through a weblink on iPads to make access easier; one grantee developed a culturally appropriate evaluation tool for naloxone overdose reversal training; and one grantee adapted its training format to better align training activities to different learning styles (e.g., organizing group sessions in a circle and using a conversational format).
Partnerships and Sustainability
FR-CARA funding facilitated communication and partnerships between EMS, county and state agencies, and other key sectors. These organizations partnered to create task forces and planning committees, co-developed and reviewed survey tools and data collection methods, and actively engaged in sustainability discussions. Grantees and their collaborating organizations created mobile data collection tools, enhanced data monitoring of overdoses via multiple streams, identified racial/ethnic disparities in the prevalence of overdoses to direct efforts, and increased educational efforts to highlight harm reduction strategies.
Naloxone trainings conducted with new partners seem to have increased substantially as a result of the FR-CARA grant funding. One grantee said that it trained 10 community professionals to be trainers. One grantee highlighted the need of training for surveillance of nonfatal overdoses and, thus, to be able to track data over time and achieve sustainability.
FR-CARA grantees highlighted that partnerships were a key component in planning and implementation of the projects. Partnerships varied in terms of the number and types of organizations, including key organizations and sectors such as corrections, courts, harm reduction programs, social services organizations, pharmacies, recovery community organizations, shelters, substance use disorder treatment entities, and syringe exchange programs.
In line with the grant objectives, partnerships were solidified in order to reach the target population with services and naloxone distribution. Some grantees described collaborative approaches to overdose prevention training and distribution of toolkits. One grantee described “Through a partnership with … Office of Opioid Safety’s Expanding Access to Medication Assisted Treatment … Program, Project … is able to provide kits to individual who are being released from … County Corrections Center and who may be at risk of overdose because of an addiction to opioids and a period of abstinence.”
Grantees and their partners developed unique pathways to secure additional or continued funding and support, inclusive of, but not limited to (1) establishment of 501c3 designation to enable donations and fundraising and (2) creation of a “county-wide coalition engaging stakeholders, including Walgreens, CVS and the Sheriff’s Office” to increase support of
drug take back via home disposal bags, pickup of unwanted medications from individual homes, a small grant of $2,500 for mail back, and installation of additional safe disposal boxes at local pharmacies.” Such take-back programs may be effective (University of Wisconsin Public Health Institute, 2017), though some studies suggest it may have a minimal impact relative to controlled medications dispensed in a given community (Egan et al., 2017).
Barriers
As with all grants and initiatives, there was a spectrum of barriers that project leads and partners faced, ranging from data collection and sharing, cost of naloxone, grant management, the COVID-19 pandemic, staffing, and communication challenges.
Data
FR-CARA grantees encountered several challenges related to data, which emerged in many stages of the program, from initial needs assessments to outcomes assessments and evaluations. FR-CARA grantees identified the existence of data gaps when conducting their needs assessment. Data gaps exist in part as a result of different data collection systems. Substantial data gaps were also evident when tracking grant outcomes. Multiple grantees struggled with nonresponse in follow-up surveys among those who participated in naloxone trainings. Strategies noted to improve response included a greater emphasis on survey response during training, printing survey link on kits, emailing reminders to fill out when naloxone was used, and reducing survey length. Grantees also encountered difficulties tracking naloxone administrations, hospital admissions, and connection to treatment. These difficulties in data collection affect both program design and evaluation.
Other key data limitations included an underdeveloped infrastructure to monitor treatment admissions, discrepancies in data on fatal overdoses across counties, suppression of county-level data on hospitalizations and overdoses due to confidentiality concerns in small/rural areas, unavailable data on treatment information and opioid overdoses, difficulties with data from the criminal justice sectors, no uniform data collection and statistics on overdoses, no unique patient identifiers in EMS databases (which makes it difficult to track repeat clients when variations in name or date of birth are provided to EMS on different occasions), and difficulty with getting prehospital providers to register kit distribution or recording opioid overdose reversals with naloxone.
Cost of Naloxone
In the interviews with NORC, grantees commented on the cost of naloxone, and of Narcan specifically. One interviewee noted:
I’m more concerned about funding for the Narcan as it gets very expensive. We have also recently looked at a different brand. It actually gives a higher dosage of the medication where Narcan is four milligrams and the alternative is an eight milligram for the same price. So we’ve been exploring that as an alternative, because then maybe you don’t have to give somebody two doses, you can give somebody one dose and it’s the same cost.
– ID 1008 (CSAP)
Grant Management and SAMHSA
Change in program officers at SAMHSA and delays in budget approvals were mentioned by several grantees as a significant reason for delays in project execution. Interviews of FR-CARA grantees conducted by NORC suggest that grantees wanted SAMHSA to be more intentional in interactions with them while being more present, including consistent communication between grantees and program officers at SAMHSA. Almost half of grantees interviewed by NORC had either a strained or nonexistent relationship with their SAMHSA Government Program Officer due to a lack of communication and/or having a new program officer assigned up to three times during their grant. Several grantees also mentioned that they wanted SAMHSA to facilitate more collaboration among grantees; some grantees were interested in learning from each other and exchanging ideas to overcome challenges. During the NORC interviews, grantees expressed interest in increasing flexibility in how they use CARA funds.
COVID-19
The FR-CARA grantees were all implementing their programs at least in part during the COVID-19 pandemic. The FY2017 cohort of grantees were implementing their programs through September 29, 2021, and the FY2018 cohort through September 2022. FR-CARA grantees identified several types of delays related to COVID-19. These delays included difficulties with completing budgeting and contracting, challenges with the staffing of project directors and coordinators, inability to rapidly execute memorandums of understanding, difficulties scheduling task force meetings, and scheduling challenges related to virtual meetings. Other issues related to COVID-19 that led to delays in implementation include the lack of availability of office space, services being closed, inability to offer train-
ings, and rural reservations not having virtual alternatives for meetings and communication.
The COVID-19 pandemic led to delays in activities such as the execution of contracts for naloxone distribution or training. As a result, there were also delays in the use of FR-CARA funds. There were also delays in staffing and team building, reassignment of FR-CARA project leads to support COVID-19 efforts in grantee and partner organizations, delays for one grantee in accessing data from project computers (a tribal community), reductions in naloxone distribution, and staff reassignments. There were also difficulties coordinating peer, therapy, and counseling sessions due to COVID-19 demands. One tribal agency grantee noted financial budget limitations during the COVID-19 pandemic:
FR-CARA Program has not been able to provider Nasal Narcan to the targeted communities, due to the COVID-19 epidemic. Trainings, face-to-face meetings and travel were put on hold and still on hold. Additionally, efforts around the agency have been limited as many people have been home due to health conditions that put them at-risk to the pandemic.
FR-CARA grantees reported that partnerships and grant progressions were heavily impacted by social distancing guidelines, lockdowns, individual safety, and resource constraints. These factors led to delays in planning and implementation, limiting delivery of training, expansion of projects, hiring of workforce, and overall communication, as in-person meetings needed to be quickly converted to phone/web-based conferences.
Staffing
FR-CARA grantees also faced staffing changes (e.g., project directors and staff transitioned to other positions), which caused delays. One grantee’s partner noted difficulties caused by having only three staff members on a project. One noted that funding for case management follow-up was challenging given limited funding.
Communication Challenges
Communication strains with partners were prevalent among grantees. Some reported that outreach to partners went unanswered, and some potential partners that were contacted for training/distribution had not responded favorably. Multiple grantees noted that EMS agency first responders were reluctant for training, leading to delays. This was not limited to EMS agencies, as grantees also reported similar challenges when trying to engage hospital staff and police departments, and one grantee noted dif-
ficulty communicating with opioid treatment programs. Additionally, one grantee noted that finding ways to communicate with law enforcement can be challenging and requires “a kind of cultural competence.” Another noted that EMS providers benefited from “credibility,” which is facilitated by a trainer with EMS experience instead of grantee staff. The committee notes that law enforcement buy-in and multisectoral collaboration are likely to be beneficial to the success of naloxone programs (Goodison et al., 2019; White et al., 2021).
The drafting and execution of contractual agreements was a common reported barrier for fortification of partnerships, leading to delays in project initiation and expansion. Multiple grantees attributed delays and limitations in project implementation to factors such as award date, time to get partners in place, and specific regional requirements or contracting. One grantee noted that even though a change in contractual arrangements ultimately was approved, project activities were delayed. Additionally, some grantees reported law enforcement agencies were reluctant to carry naloxone due to “liability risks”; this legal issue presented a barrier to partnering with such agencies. One grantee also noted that the “legal review process prevented our funded partners from incurring costs to implement linkage services, data collection and performance evaluation.”
A common barrier reported by grantees was data and linkage limitations with partners, which impacted program design, implementation, and evaluation. Rigidity of current systems and the lack of interconnectivity were barriers highlighted by some grantees. One grantee noted that the police database is not followed up on by any city agencies but did not specify why this was the case. Another grantee noted that it was working to create a lawful and ethical way for information to be utilized in following up with overdose victims, with the potential of ensuring that an increasing the number of those with substance use disorder are connected to care, which would require multiple data sharing agreements and potentially an informed consent process.
FINDINGS: OUTCOMES
FR-CARA focused on trainings for naloxone distribution and strategies to reduce opioid overdose and deaths; these activities have, as potential outcomes, overdose reversals and prevention of death from overdose.
Below, the committee highlights “accomplishments” in terms of outcomes for individuals and populations, as included in FR-CARA grantee reporting and from the qualitative interviews presented by NORC (which combine findings for FR-CARA and OD Treatment Access grantees). This is followed by comments on barriers. These comments reflect individual outcomes, and, when available, population outcomes.
Individual-Level Outcomes
SAMHSA provided information from grantees on partner-administered naloxone and their outcomes. However, the committee is unclear about the completion of this reporting. Based on the number of entries in the spreadsheets provided, it appears that these data come from 35 grantees [F18f]. Nevertheless, more than 95,000 naloxone doses were reported administered by grantees and partner organizations in FYs 2018–2021 [F18d]. Outcomes were reported for more than 95,000 overdose events [F18f]. Overdose was reported to have been reversed in more than 35,000 administration events. The outcome was unknown for the majority of overdose events reported [F18f]. The majority of administrations for which location was known were in private residences [F18e]. Grantees described circumstances of specific overdose reversals, for example, “An … employee used one of these Narcan bags to save the life of an opioid user in a court room. The employee used two doses of Narcan while waiting on emergency services to reach the location. The person under the influence was brought back to consciousness and transported to the … Hospital.” Some grantees focused on specific types of high-risk individuals. Specifically, some grantees focused on problems of specific individuals (e.g., those taking an extra dose of methadone, those combining it with other drugs). As this (and other examples) illustrate, while grantees described their focus on individuals, it is not usually clear how many individuals were affected (in terms of overdose reversal) or specific linkages in most cases to project activities (other than the first listed individual examples reporting a number of actual observed reversals of overdose, potentially preventing death in specific examples).
The NORC interviews suggest there may been broader numbers affected by the programs. Note that the findings here reflect both FR-CARA and OD Treatment Access grantees. Below is information in their summary:
Several CSAP grantees noted that “this [grant] has saved hundreds if not thousands of lives” (ID 1026, CSAP) and substantiated this claim by providing a brief story of a specific individual (see quote below) or highlighting the number of successfully administered overdose reversal drugs or the number of nonfatal overdoses that had occurred in their community:
I could tell a story about a young man that had been experiencing overdose after overdose. By going out and reaching him through the connection with [first responders], he’s doing well. You know he still has his setbacks, it’s all part of recovery, but he is doing really well and it was part of us getting in there with the Narcan. We went to a drug-using house, knocked on the door, handed them the Narcan and our business cards and said call us, and he called us.
Community-Level Outcomes
Outcomes for communities include effects of general education about substance use disorder, overdose reversal, and stigma reduction in the community.
Addressing Stigma
NORC noted that overall (across all programs), grantees commented on the broader impact their CARA grant program could have on individual attitudes and public perception on overdose and recovery by highlighting the need within their community. NORC noted that grantees identified stigma among individuals administering overdose prevention medications (e.g., first responders, key community members) and individuals at risk of experiencing an overdose. Grantees felt that individuals responsible for administering overdose prevention medication would refuse medications after trainings or be reluctant to partner with grantees due to stigma. According to the report:
The second most commonly reported success was the impact organizations had on reducing stigma in their communities. Grantees often attributed reduced stigma to both an increase in overdoses and the grant requirements—specifically educating individuals through trainings and events, including parades, conference presentations, annual staff retreats, and other recovery-focused activities. For example, one CSAP grantee described the shift in perspective among first responders as they learned who was experiencing overdoses (see quote from ID 1017). Relative to the other two programs, BCOR and FR-CARA program grantees more often identified the reduction of stigma as a success, perhaps because it was an explicit program goal.
“You know 5–10 years ago people weren’t really talking about [overdose] the way they’re talking about it now . . . it was taboo, back alley, you know a lot of judgment and a lot of stigma. Unfortunately, there is still a lot of stigma but . . . what was happening is a lot of our [first responders] are natives, they grew up here, these are their neighborhoods they’re servicing and they would be responding to overdoses at homes of people they knew and suddenly it wasn’t a distant disease anymore, it was ‘oh, I played basketball with him growing up,’ or ‘my kid plays soccer with her kid,’ and all these connections were being made. And now that . . . it’s real to them they care more. So they start calling [us] and they’d be like, ‘hey, can you help us get a bed for this person, it’s a family friend,’ or ‘it’s a friend of a friend,’ or ‘this kid just graduated,’ like these personal connections are coming out and now they want to be carrying Narcan because . . . everyone has been affected by [overdose] in some way, shape, or form
and so that buy in and that want to help the community really helps, like they are invested in helping this community.”
Barriers
The data collection barriers previously discussed limited grantees’ abilities to track population outcomes. As an example, one grantee noted data gaps in ability to track relevant information:
There are data gaps related to our inability to assess non-observable traits (e.g., employment status, poverty, sexual and gender orientation) in both naloxone administrations and overdose mortalities. One grantee noted that data limits were due to information not collected by emergency providers and public safety staff in emergencies.
NORC also identified data requests as a barrier for addressing stigma: NORC noted that grantees reported that those at risk of experiencing an overdose were less likely to receive overdose prevention medication kits if asked to complete documentation of any kind—for example, asked for a name or demographics.
More broadly NORC identified data gaps in having population impact information. Specifically, NORC noted:
Grantee evaluation efforts focused mostly on SAMHSA requirements, specifically the web-based reporting tools—GRPA and DSP-MRT. While most grantees across CSAP and CSAT programs identified other types of information that they collected outside of required reporting (e.g., client demographics, satisfaction surveys, county data on ED [emergency department] visits, client assessments, fatal and nonfatal overdoses), they noted that they often did not have the time, staff, or resources to analyze data beyond what SAMHSA required. This limited their ability to quantify impacts on subpopulations, their organizations, or the community.
NORC identified both a range of program impacts on stigma and successes in addressing challenges:
While several grantees were successful at reducing stigma in their communities through education and trainings, it remained a challenge for others. In one instance, stigma interfered with a grantee’s effort to overcome the challenge of collecting follow-up data from individuals who received and/or used overdose prevention medication. However, it is important to note that in several instances securing SAMHSA funding gave grantees the credibility, clout, and confidence to persist in the face of entrenched stigma. The CARA grant program requirements supported grantees in making
considerable inroads in their communities to change attitudes and perceptions about individuals experiencing overdose and/or in recovery.
FINDINGS: STRUCTURAL AND ENVIRONMENTAL CHANGE
Accomplishments
Owing to diverse partnerships and diverse policy and structural and environmental contexts, especially for high-risk areas and in the context of the COVID-19 pandemic, some of the FR-CARA grantees commented on or tracked structural and/or environmental changes that occurred over the period of the FR-CARA grants. Sometimes it was possible to determine whether the grantee agency or partners were responsible for or involved in the structural and environmental changes; most often when these were reported, it was not possible from the available summaries and comments to determine the source of the changes instituted.
Structural and environmental goals and impacts were primarily focused around expanding community partnerships or community agency roles, promoting policy change and advocacy or system regulation changes, addressing disparities for high-risk populations, and having the necessary data and support for these goals, and sometimes for sustainability. Many of the comments relevant to this section overlapped with comments on grantee and partner activities, but have been included here because they can be considered as having structural impact or implications.
Grantees noted goals, barriers, and work-arounds related to strcuture. For FR-CARA goals of training and distribution of overdose reversal medication and practices, the range of issues touched on in this section—such as needs for alignment with policy, engagement of key first-responder agencies as partners, building interest and capacity, and tracking data and outcomes with policy support—are consistent issues. Further, these activities are also consistent with some of the survey reports on project activities (aggregated) applying to about 33–50 percent of those who responded on those items, suggesting it is a somewhat more frequent (although not universal) activity of grantees.
Support for grantees around engagement of stakeholders and policy makers and alignment of state and local goals with national goals on issues such as the opiate crisis are important overall activities to note for planning efforts. Building policy partnerships required to address regulation challenges in advance or in parallel with project support can be considered as an important “structural and environmental” context option for supporting future efforts. That may be of particular relevance during crises such as the COVID-19 pandemic, which potentially complicated (and in some cases facilitated) policy responses.
Grantees noted a variety of state and local regulation changes that were either being considered or were passed during the CARA grant period. It was not always possible to attribute these to grantee activities directly, however. Grantees highlighted a number of such regulations that had potential to impact future programming efforts, as they concerned matters such as data access, contracting with partners, or project implementation. Some grantees discussed collaboration with or impact from state or local support for policy change. As an example, one grantee said:
The Governor’s Overdose Prevention Task Force set the objective of reducing opioid-overdose related deaths by 1/3 in three years (end date 2020). Co-chaired by the Directors of the Department of Health and the Department of Behavioral Healthcare, Developmental Disabilities and Hospitals, task force expert advisors and members of the general community convened monthly to share resources and disseminate data and program updates to streamline prevention response and highlight challenges and successes across the state. The FR-CARA grant reported grant activities to the Prevention Task Force in March 2019.
This suggests that this grantee worked to align broader goals of state policy leaders and some activities of the FR-CARA program. Another example of alignment with policy to meet program goals included: “Emergency medical services providers can carry and administer naloxone under state protocol and were tested for competency in administering this drug under state scope of practice training.” The committee notes that several types of EMS providers have been shown to be effective at administering naloxone (Gulec et al., 2018).
Another noted developing a plan for data sharing by entities within a tribe (currently in progress and being reviewed by an attorney). Another grantee noted that the state Department of Instruction approved its overdose curriculum, allowing more extension to schools. Another example of a policy change is one grantee that noted that a county had initiated a drug take-back program, adding that this increased the sustainability of project effects that had focused on a similar activity; see prior discussion on the effectiveness of drug take-back programs. Thus, it was an example of structural response for sustainability, not of the entire project but of a specific goal. Finally, one grantee noted that the state passed a law requiring reporting the number of 911 calls and number of overdose deaths (to track outcomes in future), which could facilitate data to inform programs as an example of structural change, though not one necessarily attributable to the CARA funding itself. The committee notes that it does not know whether this state law was accompanied by Good Samaritan laws; such laws with more expansive legal protections in combination with Naloxone Access
Laws may be associated with lower overdose rates (Hamilton et al., 2021), and though evidence is limited and mixed, some do suggest effectiveness in increasing calls made to EMS (Moallef and Hayashi, 2021).
Some grantees noted that external funding through policy sectors helped support their goals, with potential for sustainability. Particularly if such changes developed in collaboration with FR-CARA project support—which was not always clear—this could be considered an example of structural change. For example, one grantee cited that the state provided $5.3 million (from a lawsuit) for naloxone distribution. Another noted that its state Department of Health, as a “sister agency,” secured funding and was working to provide emergency room data (relevant to overdose reversal) to improve available grants to the grantee.
Barriers
Some grantees described structural barriers to implementing FR-CARA projects, including for law enforcement and other first responder partners and certain regions such as rural areas. One grantee noted:
Law enforcement officers and firefighters without EMS certification must be licensed to carry and administer naloxone; Resource constraints and resistance among law enforcement officers to become licensed to carry and administer naloxone caused us to focus more on Fire and EMS agencies.
Another noted:
In the rural counties, the area’s Law Enforcement and Fire/EMS authorities do not envision the Opiate Issue to be as bad and as the EMS departments currently already carry Naloxone from the hospital drug bag program (which contains Naloxone), they don’t feel the need to stock their vehicles with Naloxone. We are currently working with departments individually to show the merits of carrying the kits on all departmental vehicles but the progress is slow.
For some of these structural barriers, grantees engaged in efforts to create “work-arounds.” These strategies involved structural or environmental approaches, such as regulation of policy change. This section includes examples of barriers with “work-arounds” ongoing.
One grantee noted:
On January 31, 2019 a consent decree which was approved by a federal judge, as negotiated by the [Attorney General’s] Office and the City, instituted comprehensive reforms of the Police Department. Key provisions of the consent decree covered nine specific areas of operational and tacti-
cal reforms, including transition of key decision-making command staff for this project. This matter impacted the program by causing delays in project approvals needed to finalize policies and agreements for rollout of district trainings for long-term planning. While the program continued to move forward in planning, its strategies and contractual relationships were hampered by lack of decision-making and key approvals from senior levels of the department and legal counsel, who were re-routed to aspects of implementation for the consent decree. As a result of several unexpected delays, some of which are due to the unprecedented COVID-19 pandemic, there are now several strategies in place to ensure successful completion.
This seems to be an example of both structural barriers and approaches to work around the barriers (as part of project activities).
Another example of a barrier and “work-around” is one grantee’s development of a policy document, through local authority, aimed to help engage broader communities to participate in the project activities. This could be considered a structural barrier and solution. The grantee noted:
The Alcohol and Drug Addiction Services Board will develop a report for other communities to demonstrate the extent of the opioid crisis in their jurisdiction, the successes of active Quick Response Teams (QRT) and the resources it will require to implement and sustain an active Quick Response Team (QRT).
Just as this example illustrates the use of data to help overcome barriers or develop support for implementing programs more broadly, other grantees noted that data are needed to convince policy makers to support sustainability; and one grantee noted particularly the importance of data to inform EMS (first responder) agencies of the importance of project goals and activities.
Another example of a barrier with progress is included in the NORC interview summary concerning City Hall support for overdose support (naloxone):
So we are budgeted to have [specific overdose support] three days a week, we really can’t afford to be doing more than that, just within our budget criteria and [City Hall] were like we will pick up the extra two days of the week … so it has encouraged them to like be more focused on it. Two years ago, [City Hall] would have been like no, we’re not giving you more money and now they’re like invested into helping.
