info@ohrdp.ca www.ohrdp.ca

1

April 2013

Disclaimer

The content in this Start Up Guide is provided as a publicservice. Although we endeavor to ensure that theinformation is as current and accurate as possible, we cannotguarantee the accuracy of all information offered herein.

The commentary and advice are the work of the OHRDP andare not intended to reflect the views and opinions of theMinistry of Health and Long-Term Care, the needle syringeprograms in Ontario or any individuals consulted asstakeholders in the development of this guide.

2

TABLE OF CONTENTS

Credits and Acknowledgements ...................................................4

Inspiration from the field..................................................................6

Preface.....................................................................................................7

Ontario: A Timeline of Opioid Overdose PreventionProgramming .....................................................................................11

The 7 Steps to an Opioid Overdose Prevention Program (ODPP)

Notes on the Seven Steps ..............................................................15

Summary of the Seven Steps........................................................16

Step One...............................................................................................17

Step Two...............................................................................................20

Step Three............................................................................................22

Step Four..............................................................................................27

Step Five...............................................................................................29

Step Six .................................................................................................32

Step Seven...........................................................................................35

Appendices .........................................................................................40

Words of Wisdom..............................................................................44

References ...........................................................................................46

ODPP Building Blocks .....................................................................49

Example of a Tracking Sheet .........................................................50

3

Credits & Acknowledgements

Funding for this Guide was provided by the AIDS andHepatitis C Programs at the Ministry of Health and Long-Term Care as part of the operations of the Ontario HarmReduction Distribution Program. Thanks go to Frank McGeeand Fiona Sillars for all their support.

This Guide was primarily authored by Laura Chapman,Health Promoter with OHRDP. Secondary authors are NadiaZurba and Ron Shore, both with OHRDP, a part of KingstonCommunity Health Centres.

In many ways this document is a practical follow up to theCommunity-Based Naloxone Distribution Guidance Documentdeveloped in 2012 by the OHRDP and authored by MeghanO’Leary.

Shaun Hopkins and Chantel Marshall from Toronto PublicHealth as well as Pam Oickle and Cynthia Horvath fromOttawa Public Health were our key informants. Each wasconsulted to glean the key, transferable findings from theirefforts in establishing Opioid Overdose PreventionPrograms. They are pioneers of this work in Ontario.

Both programs were extensively consulted in the making ofthis Guide and, as such, their combined experience andexpertise provide the basis for the steps and advice that isoffered here.

4

Dr. Kieran Moore from Kingston, Frontenac, Lennox &Addington Public Health also provided critical feedback.Rebecca Henderson assisted in proofing the entiredocument.

All contributions are greatly appreciated. However, anystatements and errors of fact remain the responsibility of theOHRDP.

Thanks go to Gillian Lunny for permission to include herinspiring letter from the field.

We have lost too many. Let their memories encourage andmotivate us.

5

Inspiration from the Field:

6

April 16, 2013

Hi OHRDP!

I just wanted to send an email keeping you up to date as to how

our Overdose Prevention Program is going.

We implemented this program about 3 weeks ago and

our experience so far has been nothing but positive. Our

presentations to police services, EMS, community partners and

physicians have shown us that this program doesn’t just make

sense to us. My staff are used to presenting on a controversial

topic when they talk about our harm reduction program; but our

Overdose Prevention Program is being accepted as common

sense. This program has helped us change the conversation

about harm reduction from not just “needles in, needles out” and

it is helping us to talk about addiction in a different light as well.

We have so far done 7 trainings and have dispensed 7 kits

with very positive feedback from the Public Health Nurses and

our clients. It allowed the PHNs to have discussions with our

clients that they hadn’t had before and we are getting the picture

here that overdose is a reality for our clients. They know people

who have overdosed, it’s happened to them and they fear it.

Our experience with implementing this program is that it has

been cost effective, not overly time consuming with all the

available resources and is it’s helping us move our harm

reduction program forward. It also is reflective of what Public

Health is for; to prevent health harms and to improve population

health.

We will be providing regional training to all of our Harm

Reduction Program Public Health Nurses next week and are very

excited about expanding our program into our region.

Thanks for your foresight on this project. Having talked with

others around our country, we are very fortunate to have

proactive, evidence informed practice happening in Ontario.

Gillian Lunny

Manager, Sexual Health and Harm Reduction Programs

Northwestern Health Unit, Kenora, ON

Preface

Death from drug-related overdose has been declared aleading cause of accidental death in Ontario1. Coroner anddispensing data has indicated that the rate of opioid-relateddeaths doubled in this province in just under a ten yearspan2, 3. Each year in Ontario between 300 and 400 peopledie from overdose involving opioids1. Yet the fact remainsthat deaths from opioid overdoses may be preventable4

through education, improved prescribing practices, training,improved bystander response and the prompt administrationof an opioid antagonist such as naloxone.

While it is hard to gauge the true extent of opioid use,dependence and overdose in Canada, Ontario does havesome provincial level data available5. Data show that:

• from 2004-2009, admissions into treatment forproblem opioid use doubled in the province6

• from 2006-2011 emergency room visits in Ontariorelated to narcotics intoxication, harmful use,withdrawal, psychosis and overdose increased by250%7

• Canada is the world’s second largest per capitaconsumer of prescription opioids in the world afterthe United States8

7

• approximately 50,000 individuals are addicted toopioids in Ontario alone7

• there are currently more than 37,000 individuals onmethadone maintenance treatment in Ontarioas cited in 7.

Harm reduction programs across Ontario have begun tofocus efforts on developing Opioid Overdose PreventionPrograms (ODPPs) because deaths due to opioid-involvedoverdose may be prevented. These prevention programs arevariable but tend to have key common componentsincluding: raising awareness, community education onoverdose signs and symptoms, as well as training in first aidand medical responses. Programs may or may not include thedistribution of naloxone, a prescription-only medication thathas the ability to reverse the effects of an opioid overdose9.

Naloxone, while potentially a life-saver, cannot be seen aseffecting a simple, mechanistic reversal of overdoses in thecommunity for several reasons:

• individual health is variable

• opioid-involved overdoses often include other drugswhich suppress respiration

• opioids range in potency and dosage

Some of the greatest outcomes of ODPPs may be found inthe behavioural changes that occur when we put the issueof preventable opioid overdose on the map. People who use

8

opioids may become more aware of the risks they face whilealso learning and being supported to adopt risk reductionstrategies. Physicians and other prescribers will becomemore cognizant of the risks faced by their patients whenopioids are prescribed. Peers, family members and potentialbystanders may become more aware of the signs andsymptoms of overdose and may be better able to offerimmediate first aid and call 9-1-1.

There is particular concern over the risk of overdose amongcertain vulnerable groups, including those recently releasedfrom prison or drug treatment, people new to methadone,those who have overdosed in the past, those who areprescribed high doses of opioids and people who use othersubstances in addition to opioids10. Using opioids in anunfamiliar setting also increases risk of overdose due to thefact that cues in the surrounding environment regulatetolerance to some degree11.

Since the mid 1990’s, community-based programs in theUnited States have offered opioid overdose preventioninterventions12 referred to as OENDs – Opioid Education andnasal Naloxone Distribution programs. Between 1996 and2010 there were more than 50,000 people who participatedin such programs in the United States, resulting in over 10,000documented opioid overdose rescues with naloxone12. Theseprograms have been implemented in Illinois, Massachusetts,New York, California, and Maryland13. Approximately 50American programs were distributing naloxone as part oftheir opioid overdose prevention services in 201012.

9

A robust evaluation of OENDs has been conducted.Researchers examined 19 communities in Massachusetts, ina time-series analysis covering a 5 year period. Findingsshowed that communities where OENDs had beenimplemented had significant reductions in overdose deathrates, when compared to communities where no OENDs hadbeen implemented14.

According to the 2012 Report of the Toronto and OttawaSupervised Consumption Assessment Study, a significantproportion of study participants (65%) indicated that theycommonly inject with someone they know15. It was alsofound that 1 in 5 study participants reported havingoverdosed in the last 6 months15. Similar findings arereported elsewhere in the literature16, 17. The fact thatindividuals using drugs have witnessed an overdose, andreport having overdosed recently themselves, indicates thatthere is a window of opportunity for trained bystanders tointervene.

According to another recent study conducted in Ontario,there is reluctance to phone 9-1-1 in overdose situations. TheOverdose Response Survey, involving 450 methadoneclients and/or people who accessed local outreach servicesin the Waterloo-Wellington Region, found that in slightlymore than half of overdose cases 9-1-1 was not called or therespondents did not know if it was called17. Reasons forreluctance included: fear of arrest, losing custody of children,upsetting the victim or fear that friends and family may find out17.

10

Ontario: A Timeline of Opioid Overdose PreventionProgrammingBy the end 2012, two Needle Syringe Programs (NSPs) inOntario had successfully implemented “Naloxone TakeHome” programs at their sites. The Works at Toronto PublicHealth has established a program called “POINT”, (PreventingOverdose in Toronto) and the Site Needle & Syringe Programat Ottawa Public Health has established a program called“POPP” (Peer Overdose Prevention Program).

Both Toronto and Ottawa have a built in evaluationcomponent to their ODPP, and both are demonstratingresults. Post-administration evaluations in both Toronto andOttawa indicate that all administrations of naloxone hadpositive outcomes18. Of the naloxone administrationsreported by the POINT program in Toronto, 50% of thoseindividuals administering naloxone had received opioidoverdose prevention training within the past 36 days18.

In July 2012, the Ontario Harm Reduction DistributionProgram (OHRDP) produced a Guidance Document entitled“Community-Based Naloxone Distribution” that was madeavailable to all agencies across the province who offeredharm reduction programming. It was developed for thefollowing reasons:

• To provide context around opioid overdose in Ontario

• To allow agencies the ability to assess the benefits ofoffering Opioid Overdose Prevention Programming attheir own site

11

• To offer examples of resources that are available suchas educational and awareness posters, example orderforms & checklists, tracking sheets and other pieces ofprogram material that can be adapted and adoptedby any agency

In March of 2013, the OHRDP conducted an environmentalscan which included each core Needle Syringe Program(NSP) in the province of Ontario. Program capacity at eachsite was examined. An area of focus pertained tounderstanding where each site was in terms of establishingan ODPP. Results included the following:

➢67% of the core NSPs affiliated with each Public HealthUnit in Ontario indicated that they either:

a) had an ODPP established and operational,

b) were about to roll out the program they had

established

c) were currently working on establishing an ODPP

d) were going to establish an ODPP in the future.

➢And 33% indicated that they would not beestablishing an ODPP.

12

Of those who reported that they would not be establishingan ODPP:

➢The majority reported having a limited number of staff

➢The second largest majority indicated that staffrequired the related education and training

➢Thirdly, NSPs indicated that it was “not a priority atpresent”; two explanations emerged:

1) a concern over lack of staff to support such a program and

2) there being a lack of data regarding local rates of overdose

13

Where is your program in terms of establishing an OpioidOverdose Prevention Program?

Not going to establish an opioidoverdose prevention program

We plan to establish a programin the future

Currently working on establishingan opioid overdose preventionprogram

Program established but NOToperating yet

Program established & operatingat present

33.3% NOTgoing toestablish an ODPP

30.6% in the future

25.0%currentlyworking onestablishingan ODPP

5.6% established but notfully operational yet

5.6% fully operational

This current document will provide agencies with the “NextSteps” to follow, once an agency has decided to implementan Opioid Overdose Prevention Program.

14

7 Steps to an Opioid OverdosePrevention Program (ODPP)

Notes on the 7 Steps:The 7 Steps to an Opioid Overdose Prevention Program are notpre-determined and they may not necessarily develop in theorder specified here. The 7 Steps are intended to identify thevarious processes and components to program development.

We have developed a conceptual “building block” model ofOpioid Overdose Prevention Programs to assist inunderstanding the various components of a comprehensiveprogram. This model is to be adapted to your local environmentand to your specific organization. While naloxone allows for apotentially life-saving intervention, opioid overdose preventionefforts can occur without including naloxone in your ODPP ifthe medical or financial capacities of any agency are limited.

If your program will not include the distribution of naloxone,then providing education on recognizing an overdose, de-bunking myths about best ways to respond, recommending afirst aid response and phoning 9-1-1 can result in a greaterchance of lives being saved.

It is important to recognize that each ODPP needs to bedeveloped within its local context and tailored to the needs ofyour community. Each will look different and some ODPPs maynot be as robust as others. It’s up to each community to do whatthey can, and do it in a way that suits their resources andenvironment.

15

The 7 Steps to Starting an OpioidOverdose Prevention Program

Step 1: Establish the need

Step 2: Include people who use opioids inyour planning

Step 3: Create a program framework

Step 4: Develop protocols and choose your program materials

Step 5: (If including naloxone) write your medical directive

Step 6: Provide training

Step 7: Evaluate your program

16

7 STE

PS

17

STE

P 1

Step 1: Establish the Need

Identifying the need for an Opioid Overdose PreventionProgram in your surrounding community is the first step.Steps 1 and 2 are both necessary as parts of your communityneeds assessment. These come in many shapes and sizesand there are various established methodologies you canrefer to as you design your approach. How you do thisshould be aligned with the resources you have available andthe timeframe you have in mind.

You will want to obtain relevant and telling local data in thisstep. In addition to conducting your own needs assessment,statistics can be obtained through existing data sets.Remember, without context, statistics are simply numbersand may not be compelling or explain the current situationregarding overdoses in your community; therefore,explanations and comparisons will be necessary.

It is also important to remember that data will inevitablyunderestimate the incidence of overdose as not all arereported, and 9-1-1 is not always called. See appendix for alist of potential data sources that you might want to consider.

You don’t have to find and analyze this data all on your own.Reports and journal articles may make specific reference toyour community. Also, public health and academic institutionsmay have reports to help you assess your local context.

18

In assessing your local context, established tools such asenvironmental scans or Rapid Assessment Responsemethodologies can be adapted, adopted and put intopractice. Sometimes, this could be as simple as developinga survey and interviewing local opioid users through NSPs,methadone clinics or other venues. Local stakeholders canalso be interviewed for their insights and perspectives andpublic health units may have staff that can help with theanalysis of findings.

Understanding drug consumption patterns is important andwill inform your planning process. You will want to come tounderstand which opioids are being used, how they arebeing used (method of administration) and in combinationwith what other substances.

The following question domains can serve as the basis forqueries you make of your local community19.

1. Demographic data: understand the age, sex, andliving arrangements of people who use opioids inyour community

2. Drug use history: ask people how many years theyhave used, how they use, and if they use alone orwith others

3. Overdose history: inquire about the number ofoverdoses people have experienced, when was their lastoverdose, and if they have ever been given naloxone

STE

P 1

19

4. Experiences and attitudes towards overdose: haveindividuals witnessed others overdose, did they call911, did they provide any first aid, what they thinkwould help?

5. Attitudes towards naloxone in OverdoseManagement Programs

6. Assessing negative impacts with take homenaloxone: anticipated drug habits, potentialmedication of withdrawal symptoms from naloxonewith more opiates

*19 Adapted from Ng, E.

Storytelling is also an important part of any data collection. Don’tbe afraid to collect “qualitative” data, and try to capture the voicesand words of the people most affected by opioid overdose.

In addition to collecting data to demonstrate local need,conducting a local community needs assessment gets thedialogue going in your community. An important principle ofharm reduction is community involvement and recognitionof the expertise within our communities. This needsassessment process is not only important to obtain local data,but also to establish the networks and relationships neededto implement, support and sustain an ODPP.

STE

P 1

20

STE

P 2

Step 2: Include People who UseOpioids in your Planning

Client involvement is critical in community-based healthplanning and the principle of “nothing about us without us”is central to harm reduction. Consulting people who useopioids will strengthen and enrich your program planning.This will help inform how a program will look, work andfunction. Conducting focus groups can be a first step.Surveys are another way to get input.

Consulting people who use opioids will be helpful in anumber of ways. They will help determine whether or notthere is a willingness to participate in an opioid overdoseprevention program. They can assist in determining whichsupplies to include in your program’s overdose preventionkits and help discern which promotional materials will havethe most impact. This consultation process also allowsinsight into how people currently perceive overdoses andhow they are responding to them.

Overall, an engagement model of community-based healthplanning includes people who use opioids in every step ofprogram development.

You may want to consider forming an advisory committeeincluding people who use opioids to enrich this dialogueand deepen the sense of community ownership. Thiscommittee could also be a “working group” which oversees

the needs assessment process and then provides advice intoprogram design, implementation and evaluation.

This stage of your program development will also help raiseawareness about overdose prevention within thecommunities you will want to reach. When a peer becomesactive in overdose prevention and participates in thetraining you put into place, they are able to provide animportant, perhaps life-saving intervention within theircommunity. It’s important to recognize the value ofinvolving people who use opioids in your planning on threelevels: to the individual, to your program and to thecommunity at large.

21

STE

P 2

22

STE

P 3

Step 3: Creating a Program Framework

A program framework sets the parameters within which yourODPP will work. It establishes your key components,objectives and philosophy. It consolidates your partnershipsand brings local stakeholders into your planning efforts. Italso outlines expectation, clarifies stakeholder roles andidentifies intended outcomes.

3.1 Partners & Regulatory Bodies Keep in mind that an ODPP is intended to save lives.Permission is not necessarily needed from all parties whohave a stake in this type of programming; however, the moresupport that can be garnered at this stage, the less resistancethere might be down the road.

Potential regulatory bodies/authorities to involve couldinclude:

• The College of Physicians and Surgeons of Ontario(CPSO), Ontario Medical Association (OMA), RegisteredNurses Association of Ontario (RNAO), Ontario College ofPharmacists (OCP), College of Nurses of Ontario (CNO);

• Local police authorities

• Your legal counsel and insurance provider

• Your Local Health Integration Network

Obtaining letters of support can strengthen efforts tomobilize your program.

An ODPP will consist of eligible clients, those able toadminister the training, and, if naloxone is going to bedistributed, a prescriber. Partners would involve anyonewith a stake in the issue, a mandate to reduce drug-relatedharm, or resources to be leveraged.

Potential partners could include:

• Local Emergency Medical Services

• Local Firefighting services

• Centre for Addiction and Mental Health local staff

• Community Health Centres (CHCs)

• AIDS Service Organization (ASO)

• Public Health Units

• Methadone clinics

• Any other Needle Exchange Partners and satellite sites

• Shelters

• Drug user advocacy groups

• Academic centres (to help with evaluation)

• Local hospitals, Emergency Departments

• Local pharmacists

*Remember: The above lists are by no means exhaustive, asa variety of stakeholders will continue to emerge as ODPPsevolve and become established.

23

STE

P 3

3.2 FrameworkDetermining where and in what framework an ODPP fits willlend credibility to the program and provide direction in theplanning process. For example, the POINT programoperating at The Works, Toronto Pubic Health fits within the4-pillar drug policy under the harm reduction pillar. ThePOPP program operating at The Site Needle and SyringeProgram, Ottawa Public Health did the same.

Having a framework helps position the objectives andpurpose of your program. Any framework serves as the“lens” through which you see the problem. In this case, youwill want to ensure your framework makes reference to thefollowing:

• Harm reduction as the guiding operating principle

• Drug use is positioned as a health issue

• Opioid overdose is often preventable, and reversible

• People who use opioids should be respected and theirdrug use understood

• The lived experience of people who use opioids is anasset for your program

• ODPPs serve as a public health and community healthasset

• ODPPs provide opportunities to develop newpartnerships

• ODPPs save lives

24

STE

P 3

ODPPs can serve additionally as a larger springboard toeducate the public, policy-makers and service providers onmatters related to drug use, addiction and stigma.

Your ODPP may be positioned as part of a Needle SyringeProgram harm reduction program, or community healthclinic. It’s up to you to determine the best fit, but generallyyou want to build on previous harm reduction initiatives andresources because these programs are already seeing thetarget population for the ODPP.

3.3 Logic ModelAt this point you will want to develop a program logicmodel. Knowing what inputs are needed ahead of time andknowing what should be measured will not only allow anagency to better comprehend understand the scope of itsprogram, but will also allow for evaluation. Logic modelshelp you to identify your outputs, outcomes and objectivesin both the short and long term.

Also at this time you will want to consider settingbenchmarks or targets as this can help steer programplanning, training and evaluation efforts. For example, youmay plan to train 15 people in your first group trainingsession, or aim to train 15 people as individuals (one at atime), in your first month.

You will need to ensure in your planning efforts that yourealize the impact of an ODPP on your staffing resources andbe sure to allocate adequate staffing. Some programs have

25

STE

P 3

noted that they did not anticipate the number of staff thatwould be required to implement and maintain their OpioidOverdose Prevention Program. Setting benchmarks ortargets and using a logic model may again assist in settingrealistic, achievable goals.

26

STE

P 3

27

STE

P 4

Step 4: Develop Protocols and Chooseyour Program Materials

Protocols define the operating structure of your program.These will be tailored to the results of your needs assessmentand be informed by the consultations with peers andpartners in your community.

Program materials might include: training presentations,manuals and guidelines, standardized documentation formssuch as agency checklists, pre-post trainee knowledge tests,client overdose history forms, instructor checklists as well aspromotional material such as posters, pamphlets andpromotional materials. If you are including naloxone in yourODPP, you will want to develop evaluation-related forms forthose who have received naloxone as well as for those whohave administered naloxone.

Ordering naloxone and assembling overdose preventiontraining kits could also occur at this stage, if applicable.Remember, phoning 911 is advised in all overdose situations,whether naloxone is administered or not. This message iscentral to your training package.

As an agency, you will need to decide on how and when toteach resuscitation - chest compression, rescue breathing,or both – as the preferred bystander respond to a suspectedoverdose. This is further discussed in Step 6 with referenceto the training you provide as part of your ODPP.

It is important to note that there are different opinions aboutwhich first aid response to teach your program participants.Toronto Public Health and Ottawa Public Health bothoperate under a protocol that encourages chestcompressions whereas the common practice in Americanprograms is to train people in rescue breathing.

If you are including naloxone, the physician issuing themedical directive (Step 5) needs to decide on therecommended first aid response that will accompany theadministration of naloxone. Refer to Section 4: OverdoseResponse: Best Practice Recommendations in theCommunity-Based Naloxone Distribution Guidance Documentfor more information from the leading first aid regulatorybodies in Canada on this topic.

Whichever protocol you teach, your training shouldencourage placing the person in the recovery position andcalling 9-1-1.

Visit www.ohrdp.ca to view and order the Community-BasedNaloxone Distribution Guidance Document which contains acompilation of example program materials, protocols,checklists, evaluation forms, etc.

28

STE

P 4

Step 5: If Including Naloxone, Write your Medical Directives

Naloxone is available by prescription only in Canada. Bothphysicians and nurse practitioners can prescribe naloxonedirectly to patients. In the case of ODPPs however, theindividual receiving the naloxone may not have directcontact with the prescribing physician. The naloxone isprovided along with training on how to respond to anoverdose.

Within these programs, the distribution of naloxone isgenerally delegated to other staff through a medicaldirective from a physician. Nurse practitioners may prescribeand dispense naloxone directly to a client; however, theycannot delegate the dispensing of naloxone to other staffsuch as physicians are able to do.

Medical directives are not person-specific but they are role-specific. However, they need not be limited to regulatedhealth professionals only. A person in a designated role mustmeet certain criteria established in the directive and possess“the appropriate knowledge, skills and judgment” 20 to carryout the action the medical directive pertains to. If a person inthis role satisfies this criteria and the training requirements,they have the capacity to carry out what the medical directivespecifies, in this case, to distribute naloxone to another personin need.

29

STE

P 5

Medical directives in essence, extend a physician’s authority;therefore the physician is responsible for anyone to whomtheir authority is delegated. All physicians therefore givemedical directives careful deliberation. This canunderstandably cause some apprehension on the part of thephysician unless specific measures are put in place to ensurethat comprehensive training is offered, that safe storage andhandling of naloxone on agency premises is ensured and thatmeasures for continuous quality review of these processesare in place.

The physician must assume responsibility for the medicaldirective that will allow staff at an agency the ability todistribute naloxone as part of an overdose prevention kitafter this person has received the required training. Yourmedical directive will specify whether the staff distributingnaloxone can be nurses or other frontline staff such ascounsellors. It is up to the physician authoring the medicaldirective to determine who possess the knowledge, skillsand judgment to be able to distribute naloxone. ODPPs inOntario have to-date delegated this act to either nursingstaff and/or counselors.

Public health physicians have developed ODPP medicaldirectives in Ontario and may be willing to play a role in yourinitiative. Alternately, physicians within Community HealthCentres or Family Health Teams may be willing to participate.Most communities have some physicians already active inpublic health, community medicine, addictions or harmreduction programming.

30

STE

P 5

Consider the following, when seeking a physician for your program:

• Family Health Teams

• Community Health Centres

• Methadone clinics

• Public Health Agencies

• Agencies affiliated with your own

Further information about medical directives can beobtained on the College of Physicians and Surgeons ofOntario website, from Physician Advisory Services of Ontarioor by visiting the Federation of Health Regulatory Collegesof Ontario (FHRCO) website where a comprehensive guideand toolkit for writing medical directives can be found.Templates within the toolkit are in compliance withlegislation and FHRCO policy. The website address is:http://www.mdguide.regulatedhealthprofessions.on.ca/templates/default.asp

Additional information can be found on the College ofNurses of Ontario (CNO) website, under Standards andGuidelines, Authorizing Mechanisms. The website address is:http://www.cno.org/learn-about-standards-guidelines/publications-list/standards-and-guidelines/

For other examples of medical directive that can be adapted as needed, visit www.ohrdp.ca

31

STE

P 5

Step 6: Provide Training

Once your program is ready, it is time to focus on training. This isthe exciting stage in which “rubber hits the road” and the programstarts to seem real. You will need to identify who will deliver yourtraining, and ensure a location and timing that is accessible to yourpopulation. You will also want to ensure you have all the trainingand program resources that you will need on hand.

The purpose of training is to prepare individuals to respond to asuspected opioid-related overdose. You will be providing them withboth information and the techniques they can practice in a critical,stressful moment. Training should be clear, supportive, andpresented in a way that matches the learning style of the individual.Training can be provided in a group setting, or on an individual basis.

Recommended training topics include:

1.Drugs, drug classifications , overdose risks, riskreduction and overdose prevention

2.How to recognize an overdose – signs & symptoms

3.De-bunking common myths regarding overdose response

4. How to respond to an overdose, including the call to 911

5.Role playing overdose situations to practice the skills

6.Naloxone: how it works, how to administer, postadministration, observation and refill procedures

7.First Aid Responses: chest compressions, rescuebreathing or full CPR.

8.How to interact with Emergency Medical Services

32

STE

P 6

and the police

9.What to expect after an overdose encounter: the roleof debriefing, responder aftercare & naloxone refillprocedures

Pros and Cons of Various Training Settings

Table 1

33

1-1 training

Grouptraining

Client/Peer only

Staff only

Combinationof Staff andClients/peers

Easier to maintain & ensureconfidentiality around anyself-disclosureYou can “capture” individualswhen they appear; some mayhave difficulty attendingpreset meeting times

Richer discussion aroundcurrent responses to (andshared experiences with)overdosesStrengthened awareness raising among all participants

Awareness raising amonghigh risk groupImportant to train others whomay be in contact with someone who might overdosePotential for more self-disclosure(vs. when staff are present)

Ability to share expertise More self-disclosure ofpotential biases & myths (vs. when clients are present)

Shared perspectives can yield insight on both sides

No opportunity toreceive or givefeedback to peers

Harder to ensureconfidentialityRisk of somemembers “takingover” while otherswill say nothing

Inability to hear fromtrained medical staffand/or familymembers as well asany other potentialbystanders

Inability to hear first-hand experiencesfrom clients andpeers

Confidentiality ofeither party may feel threatenedTraining must beprovided at the mostaccessible level

STE

P 6

Pros Cons

Where the training will be offered is another consideration.Finding appropriate space that can provide confidentialityis important. Agencies may offer training on site, throughoutreach programs and in their vans, and may include thetraining staff at partner agencies such as shelters.

You will want to ensure the training you design and deliverhelps you to meet all of your program goals and fulfills thecriteria of your medical directive, if offering naloxone.

For examples of training guides currently being used, visitwww.ohrdp.ca

34

STE

P 6

35

STE

P 7

Step 7: Evaluate your Program

Whenever you implement a program or service, it is best tomonitor both its processes and its outcomes in order toensure it is meeting the goals you have set. With ODPPs, youwill want to know a few key things. These will help you trackthe program’s outputs, outcomes and benefits. You may findthings you can improve upon; in this way evaluation helpsyou stay on top of program planning and allows you tocontinue to develop and refine your program. Conductingevaluation also shows people you care to hear about howthis impacts them, and it can give you, your staff and yourparticipants a real boost to see your program successes.

With ODPPs you will want to have an evaluation plan whichlooks at process measures, outcomes, and tracks participantand program activity. Your program logic model may serveas the basis for your evaluation plan.

You may consider the following:

➢Feedback from clients who follow up afteradministering or receiving naloxone will be valuableinformation to incorporate into ongoing process andoutcome evaluations. For example, identification ofwhich response steps were followed and which werenot can be fed back into the training and either usedto adjust training or place more or less emphasiswhere it makes sense.

➢Outcome evaluations can also include trackingoutcomes at pre-determined intervals of time afterprograms become operational.

➢Evaluation and tracking can be incorporated into pre-existing systems at any agency.

➢When tracking, consider the following:

• # of staff trained in opioid overdose prevention

• # of peer workers trained in opioid overdose

prevention

• # of clients trained in opioid overdose prevention

• # of clients trained to administer naloxone

• # of naloxone doses administered in overdose

situations

• # of naloxone kits distributed to clients

• # of clients who administered naloxone

• # of clients who reported receiving an injection of

naloxone

• # of naloxone refills distributed

36

STE

P 7

• length of training sessions

• any complications such as needle stick injury, side

effects, incorrect doses, # of units wasted/ lost/

stolen and non-referrals to 9-1-1

This list is not exhaustive and is based on what existingprograms have determined is important data to collect. At aminimum, you will want to collect the number of clients whohave been trained, received kits, received naloxoneadministration or who have administered naloxone as part oftheir ODPP. You will want to decide on a schedule to providerefresher training and how frequently it will be offered.

It has been recommended that you consider the followingwhen tracking and following up on your ODPP programactivities19:

• A monthly or bimonthly interview should beconducted to monitor the participants’ activities.

• In addition, participants should contact staff afterexperiencing or witnessing an overdose (within 1 – 2 days) so their kits can be replaced and relevantmarkers can be monitored (including: the setting ofthe overdose, the involvement of emergency services,and the outcome of the event).

• If possible, the overdose event should be confirmedby one or two other witnesses.

37

STE

P 7

• Be persistent in tracking. Participants should befollowed for a long enough period of time which willallow an agency the ability to fully evaluate programeffectiveness.

*19 Adapted from Ng, E.

For example evaluation templates & forms visitwww.ohrdp.ca to access the Community-Based NaloxoneDistribution Guidance Document

Your evaluation plan should be finalized before youimplement your training or any other activities and shouldhave measures to assess each part of your program,including the effectiveness of the training itself. It wouldhelpful to have an electronic tool for evaluating your ODPPin place prior to implementation. A sample spreadsheet isprovided in the appendices of this manual. Over time, trendswill emerge which can provide useful program planninginformation.

Evaluation is sometimes seen as “extra work” and certainlymany harm reduction programs have resources that arealready being stretched. Consider having an external partnerhelp develop your program plan, but ensure that you haveone. A plan is necessary for your program to have intention,and for you to monitor and respond to your successes andthe areas upon which you can improve. At the end of theday, evaluation helps to establish the need for, and thequality of ODPPs across the province. Talk to other programsand see what their evaluation plans look like.

38

STE

P 7

Opioid Overdose Prevention Programs are important publicand community health interventions which are still in theirearly stages in Ontario, and in Canada. Anything we can learnto improve their reach, impact and effectiveness furthers ourefforts to save lives.

39

STE

P 7

Appendices

Lessons LearnedSuggested data sources

To gather data you may want to consult some of thesesources: coroner’s offices, emergency departments,emergency medical services (EMS), methadone prescribers,agency databases & records, poison control centres andspecific external databases an agency might have access tosuch as the National Ambulatory Care Reporting System(NACRS) and the Discharge Abstract Database (DAD).Ontario data on opioid prescription rates by county and thecorrelation of these rates with mortality have beenpublished21. The Drug and Alcohol Treatment InformationSystem (DATIS) in Ontario and data from I-Track (PublicHealth Agency of Canada) are other valuable sources ofuseful statistics. In addition to overdose reports, potentialdata queries could include local drug consumption patterns,opioid prescription rates, number of people on or seekingmethadone treatment, etc. Remember, this exercise doesnot need to be comprehensive or academic; you are justtrying to understand local need.

40

Time available to train

Scenarios arise in which staff have limited time to providetraining; therefore, the time it takes to train a person mustbe adjusted according to circumstances. For example, aclient may have a limited amount of time to dedicate toreceive the training if they indicate that they are havingstrong urges to use. Those who offer training will inevitablyhave to adjust the length of time it takes to educate a personwithin reasonable limits from time to time; however, trainersmust ensure that training components have met the medicaldirective that has been put into place. For many clients thismay be the first time they have ever felt safe enough to talkabout overdose experiences. They will need time to talk.

Size of Training Sessions

Different size groups have different advantages anddisadvantages but smaller groups can sometimes presentfewer challenges to trainers. Adequate staffing can alleviatethis to some degree; however, having larger groups due toa limited number of staff might be a reality for someagencies. Review table 1 for advantages and disadvantagesthat have been noted by opioid overdose preventiontrainers. You may want to consider providing individualcertification in addition to group training. This may allow forbetter assessment of individual readiness.

41

Evaluating Program Outcomes & Effectiveness

Opiate overdoses are affected by a number of factors.Despite evidence that a program has been effective by postadministration follow-up with positive outcomes, rates ofoverdose may persist with emerging opiates and other drugtrends. Still, there are numerous reports of positiveevaluation, especially from the United States (see theMassachusetts evaluation14).

Advice about medical directives:

Your participating physician will greatly expedite the workof the medical directive. Medical directives are common inareas such as immunization and they can facilitate improvedpatient care and outcomes.

Alluding to examples of medical directives that exist forparallel, more commonly known and more widely acceptedinterventions such as immunization, Epi-Pens® to respondto anaphylactic shock or antibiotic prescribing for STI’s cannormalize efforts to create an ODPP and perhaps lessenmisunderstanding about the liability that can sometimessurround writing the medical directive for naloxonedistribution.

Highlighting the safe nature of naloxone may also help putskeptics at ease. There are no contraindications to naloxoneexcept in cases where hypersensitivity is already known.There have been no documented overdoses by naloxone,

42

and naloxone has no street value or ability to result inintoxication. Anyone can be trained to administer it withease and its effectiveness demonstrated in reversing anopioid overdose can go a long way when programs areadvocating the implementation of Opioid OverdosePrevention Programming their community.

First Aid Responses:

There is debate about which first aid response is best in anopioid overdose situation. Some guidelines stress theimportance of basic airway management and ventilation,due to the effect that an overdose has on the person’sbreathing which in turn affects organ performance/function.Other guidelines indicate the need for chest compressiononly. For more considerations of the issues please refer tothe Section 4: Summary Q and A of Evidence for CPR BestPractice in the Community-Based Naloxone DistributionGuidance Document for on www.ohrdp.ca

43

Words of Wisdom

These are culled from interviews and discussions withexisting ODPPs in Ontario.

1. “Have a policy direction”. Determine what kind ofauthority you have within the policy or framework anddetermine where you can go to get approval.

2. “Build rapport and trust among partners”with both current and potential partners and be sureto manage any and all issues that arise in a prompt andcourteous manner.

3. “Consider the 3 Questions: Do we need it?Can we do it? Can we sell it?”

4. “What is the liability and how will youmanage it?”

5. “Don’t get too far ahead of yourself.”Within reason, tackle each step before trying to tacklethe next.

For example, if your agency is going to implement theeducational and awareness raising components of anODPP, recognize that a community needs assessmentand consulting people who currently use drugs are stilltwo vital steps to take before implementing such aprogram/campaign in your community.

Another example is if your agency is able to distributenaloxone kits to trainees, try a “phased in” approach

44

beginning with highest risk or ‘captive’ groups such asmethadone clients. This will enable greater opportunityfor feedback that can inform both process andoutcome evaluations that will help to shape yourprogram in a way that responds to unique communityneeds.

6. “Don’t underestimate the power of media”,positive as well as negative. Consider launching orpromoting your program on International OverdoseAwareness Day, held on August 31st each year.

7. “Develop strategies for evaluating yourODPP early in the planning stages”. Havingthe ability to demonstrate effectiveness throughevaluations adds to accountability and will result inprogram longevity.

8. “Collect comprehensive information whende-briefing” with a person who has administeredand/or received naloxone. Keep questions open-endedwhere possible. Consider by beginning with simplyasking “What happened?”

9. With permission from clients, “consider collectingaudio recordings of debriefing sessions” fortraining and advocacy purposes.

10. “Don’t be shy”- contact OHRDP for support orreferrals to existing ODPPs and further advice.

45

References

1. Ontario Public Drug Programs Division. Ministry ofHealth and Long-Term Care. Notice from the ExecutiveOfficer. February 17, 2012.

2. Dhalla, I.A., et al., (2009). Prescribing of opioidanalgesics and related mortality before and after theintroduction of long-acting oxycodone. CanadianMedical Association Journal. 181 (12).

3. Office of the Chief Coroner of Ontario.

4. Ontario Harm Reduction Distribution Program. (2012).Community-Based Naloxone Distribution GuidanceDocument.

5. Canadian Centre on Substance Abuse. (2013). Canadiandrug summary: Prescription opioids. www.ccsa.ca.

6. Fischer, B., Nakamura, N., Rush, B., Rehm, J. & Urbanoski,K. (2010). Changes in and characteristics of admissionsto substance use treatment related to problematicprescription opioid use in Ontario, 2004-2009. Drug andAlcohol Dependence, 109, 257-260.

7. Expert Working Group on Narcotic Addiction. (October2012). The way forward: Stewardship for prescriptionnarcotics in Ontario.

8. International Narcotics Control Board. (2013). NarcoticsDrugs: Estimated World Requirements for 2013;Statistics for 2011. New York: United Nations.

9. Product Monograph: Naloxone Hydrochloride InjectionUSP. Sandoz Canada Inc. September 30, 2005.

46

10.Dasgupta, N., Brason F. W., Albert S., Sanford, K. (2008).Project Lazarus: Overdose prevention and responsiblepain management. North Carolina Medical BoardForum 2008; 1:8-12. Retrieved: 2013 May 10.www.ncmedboard.org/images/uploads/publications_uploads/no108.pdf.

11.Siegel, S. & Ramos, B. (2002). Applying laboratory research:Drug anticipation and the treatment of drug addiction.Experimental and Clinical Psychopharmacology 10 (3);162-183.

12.Centres for Disease Control and Prevention (CDC).Community-based opioid overdose preventionprograms providing naloxone- United States, 2010.Morbidity and Mortality Weekly Report. 2012; 61:101-5.

13.Doe-Simkins, M., Walley, A., Epstein, A., & Moyer, P.Saved by the nose: Bystander-administered intranasalnaloxone hydrochloride for opioid overdose. AmericanJournal of Public Health. 99 (5), 788-791.

14.Walley, A., Xuan, Z., Hackman, H., Quinn, E., Doe-Simkins,M., Sorensen-Alawad, A., Ruiz, S. & Ozonoff, A., (2013).Opioid overdose rates and implementation of overdoseeducation and nasal naloxone distribution in Massachusetts:Interrupted time series analysis. British Medical Journal.436:f174. Doi10.1136/bmj.f174.

15.Bayoumi A., Strike, C, et al. Report of the Toronto andOttawa supervised consumption assessment study,2012. Toronto, Ontario. St. Michael’s Hospital and theDalla Lana School of Public Health, University ofToronto.

47

16.Fischer, B., Brissette, S., Brouchu, S., Bruneau, J., el-Guebaly,N., Noel, L., Rehm, J., Tyndall, M., Wild,C., Mun, P.,Haydon, E. & Baliunas, D. (2004). Determinant ofoverdose incidents among illicit opioid users in 5Canadian cities. Canadian Medical Association Journal.171(3), 235-239.

17.Follett, K., Piscitelli, A., Munger, F. & Parkinson, M.(2012). Between life and death: The barriers to calling 9-1-1 during an overdose emergency. Waterloo RegionCrime Prevention Council. Retrieved fromhttp://www.preventingcrime.ca/documents/OverdoseReport.pdf

18.Hopkins, S. & Oickle, P. Community-based naloxoneprograms: A harm reduction approach to overdoseprevention. Powerpoint presentation. Delta Chelsea.Toronto, Ontario. 2011 Feb 2.

19.Ng, E. Investigating naloxone (Narcan) peer distributionas an overdose harm reduction strategy in Toronto.Powerpoint presentation. Sunnybrook Health SciencesCenter. Toronto, Ontario. 2007 April 27.

20.Tanchak, S., & Goldig, B. "Comprehensive guide andtoolkit provides templates for medical directives." OfficeConsult. Apr 2007: 26-27. Retrieved: 2013 Apr 11.http://www.cpso.on.ca/uploadedFiles/policies/policies/policyitems/medicaldirectives_april07.pdf

21.Gomes, T., Juurlink, DN., Moineddin R., Gozdyra, P.,Dhalla, I., Paterson, JM. & Mamdani, MM. Geographicvariation in opioid prescribing and opioid-relatedmortality in Ontario. Healthcare Quarterly. 2011. 14 (1);22-24.

48

ODPP Building Blocks:

Step 1: Establish the need

Step 2: Include people who use opioids inyour planning

Step 3: Create a program framework

Step 4: Develop protocols and choose your program materials

Step 5: ( If including naloxone) write your medical directive

Step 6: Provide training

Step 7: Evaluate your training

49

Chart 1: Example Tracking Sheet made in Excel

50