Assessment of knowledge and behaviors of an opioid overdose education and naloxone distribution program during the coronavirus disease 2019 pandemic

Abstract

Background

The state of Louisiana ranked 4th in the US for per capita overdose rates as 56 out of 100,000 persons died due to overdose and 1,300 of those deaths involved opioids. Opioid involved deaths increased 131% between 2019 and 2022. A pharmacist-led opioid overdose education and naloxone distribution (OEND) program was developed at a SSP in New Orleans during the COVID-19 pandemic. The purpose of this research is to characterize the clients who participated in the OEND and to assess their learned knowledge and behaviors over time.

Methods

A pharmacist led OEND program was created in April 2020 at a syringe service program (SSP) in New Orleans, Louisiana. OEND was provided by a licensed pharmacist and student pharmacists. OEND coincided with the SSPs activities one time a week. Participants first received harm reduction supplies through the SSP and then had the option of receiving OEND. Patients' demographic information was collected. Participants who said they received opioid overdose education from our OEND program were verbally given a knowledge and behavior assessment. Participants knowledge and behaviors were scored using a rubric.

Results

A total of 32 OEND sessions were held from July 2020 through February 2023 resulting in 1453 overall participant interactions. Repeat participants completed 269 visits and averaged 2.3 visits in three years. The average age of participants who received OEND was 40 years old. Additionally, participants who accessed OEND were primarily white (67.77%, n = 811/1300) and mostly male (59.15%, n = 769/1300). Among the participants who visited the OEND station more than once, 160 responses were collected for how helpful the previous education session had been. Of these responses, 75% (= 120/160) were “Very helpful”. Participants who repeated the program retained knowledge and showed a positive change in their behaviors regarding opioid overdose reversal.

Conclusions

OEND programs established at SSPs play an important role in providing education to PWUD. Participants knowledge sustained over time; however, refresher education sessions may be valuable to ensure participants stay accurately informed. Participants find OEND helpful. As naloxone continues to become increasingly available, OEND is necessary in preventing opioid overdose deaths.

Background

The United States (US) experienced 80,411 opioid-involved deaths due to overdose in 2021, which is an increase from ~ 50,000 at the start of the coronavirus disease 2019 (COVID-19) pandemic [1]. The COVID-19 pandemic is associated with an increase in opioid overdose deaths [2]. A contributing factor in the complexity of public health issues regarding the rise of opioid overdose deaths is a decrease in resources for people who use drugs (PWUD) like the closure of substance use treatment and harm reduction resources [3,4,5]. During the pandemic, opioid overdose deaths involving synthetic opioids, like fentanyl, increased over 22% [6]. The state of Louisiana ranked 4th in the US for per capita overdose rates as 56 out of 100,000 persons died due to overdose and 1,300 of those deaths involved opioids [7]. The Louisiana Department of Health reports 2,722 drug-involved deaths in 2022 and 15,665 documented drug poisoning-related emergency room visits in 2021 [8]. Additionally, Louisiana providers prescribe an average of 72 opioid prescriptions per 100 individuals, which is down by 2.7% from 74 prescriptions in 2020. [9]

In response to increasing overdose rates, federal and state-wide initiatives improved access to naloxone, a lifesaving medication to prevent opioid overdose. Prevention of opioid induced mortality is directly related to the administration of naloxone in a timely manner [10, 11]. Having higher distribution of naloxone can avert 21% opioid overdoses in communities [12]. Syringe service programs (SSPs) are ideal environments to supply individuals who are at high risk of opioid overdose or witnessing an opioid overdose access to opioid overdose education and naloxone distribution (OEND). A survey of SSPs in the United States in 2019 found that 94% (247/263) of SSPs that responded provided some form of OEND. However, 6% (n = 14/263) of those SSPs provided most of the total naloxone distributed, meaning that most OEND occurred in centralized locations [13].

OENDs are a valuable, evidence-based resource for people who use opioids in both the clinical and nonclinical setting [14,15,16,17,18,19]. The foundation of OEND is to change behaviors and knowledge of individuals in response to opioid overdose through education and resources. Best practices center around ensuring people have easy and consistent access to naloxone at no cost [20]. These programs vary in type, including telephone-based services and face-to-face programs [21, 22]. Most OEND training is provided by public health professionals and medical professionals [23]. The typical educational components of an OEND program includes evaluating for signs of an opioid overdose, calling 911 for help, how to administer naloxone, support the person’s breathing, and monitoring for response [24]. Participants who receive this education are usually given naloxone and other harm reduction supplies if available. Though OEND programs are associated with decreased rates of opioid related mortality, safety precautions during COVID-19 became a barrier in providing these programs at a time when they were needed most.

A pharmacist-led OEND program was developed at a SSP in New Orleans during the COVID-19 pandemic in response to increased client enrolment during that time. The SSP actively distributed naloxone to clients; however, in discussions with clients, we discovered the need to implement education on opioid overdose reversal using naloxone. During 2021, 94% (462/492) overdose cases in New Orleans tested positive for fentanyl [25]. Opioid involved deaths increased 131% between 2019 and 2022 [26]. The creation of the Pharmacist-lead OEND program filled an unmet need for the SSP at that time. The purpose of this research is to characterize the clients who participated in the OEND and to assess their learned knowledge and behaviors over time.

Methods

Program description

A pharmacist-led OEND program was created in April 2020 at a high-volume syringe service program in New Orleans, Louisiana. OEND was provided primarily by a licensed pharmacist and student pharmacists. The SSP held services once a week for 5 hours and the OEND program coincided with the SSP activities once or twice a month. Participants first received harm reduction supplies through the syringe service program and then had the option of receiving OEND. At the start of the training session, participants were asked if they wanted to receive opioid overdose education as well as naloxone. During the height of COVID-19, after stay-at-home restrictions were relaxed, OEND occurred outside with participants and trainers standing 6 feet apart at separate tables. The pharmacist and student pharmacists wore street clothes to blend into the environment of the SSP. Each pharmacist or student pharmacist educated one person at a time wearing personal protective equipment (PPE). Through the years, the program followed COVID-19 distancing recommendations and moved indoors, and PPE use was always encouraged. If a participant agreed to the education session, a pharmacist conducted the intake. Data collected for the intake session was used for quality improvement purposes of the program, and then later retrospectively evaluated. During the intake session, each participant was asked to provide their patient code (first two letters of their first name, first two letters of their last name, day of birth, and last two numbers of their year of birth) which is the code they used to sign-in with the syringe service program. Then participants were asked for unidentifiable demographic information such as the participant’s age, gender identity, sexuality, race, ethnicity, type of insurance, previous experience overdosing or witnessing an overdose, highest level of education, and parish of residence. Once the data was collected, the participants then went to a second station where they received opioid overdose education as well as naloxone. We also supplied participants with harm reduction tools like fentanyl test-strips later in our programing when they became legalized by our state legislation. Participants were encouraged to come by the OEND station, even if they’ve visited previously.

Knowledge and behavior assessment

Participants who said they received opioid overdose education previously were verbally given a knowledge and behavior assessment quiz (Table 1). Instead of receiving the formal training where a trainer educated the participant on opioid overdose education, the trainer used the “teach-back” method to quiz the participants on the steps to identify an opioid overdose. Participants were scored on their knowledge and behaviors of opioid overdose management. Participants either received the following for knowledge: No knowledge (0–2 correct answers), minimal knowledge (2–4 correct answers), basic knowledge (5–7 correct answers), adequate knowledge (8–9 correct answers) and superior knowledge (10 correct answers). The behavior assessment was scored with the following scale: not appropriate behavior (0–2 correct answers), rarely appropriate behavior (2–4 correct answers), inconsistently appropriate behavior (5–7 correct answers), usually appropriate behavior (8–9 correct answers), and consistently appropriate behavior (10 correct answers). After trainers scored the participant, the final score was relayed to the intake person who documented the results next to the participant's code. Due to the high volume of clients that needed OEND and limited time of each OEND session (approximately 5 minutes), the pharmacy team decided this method fit our program best instead of tracking individual scores for each client on paper or electronically. Then the participant's knowledge was reinforced with correct answers and further education. Participants could only receive opioid overdose education once per day that the sessions were offered.

Table 1 Knowledge and Behavior Assessment Rubric

Statistical analysis

Collection and initial organization of the data was carried out with Microsoft Excel. In line with the goal of this study to characterize the visitors of the OEND, descriptive analysis was conducted using STATA 14.2. (StataCorp LP, College Station, TX, USA). This consisted of computing frequencies and percentages for all the different variables given their mostly categorical nature. For age however, the mean was computed since this is a numerical variable.

Knowledge was converted into a binary variable with two categories: "Sufficient Knowledge" and "Insufficient Knowledge". Observations with “Adequate Knowledge” and “Superior Knowledge” were classified as sufficient knowledge, and all other categories were classified as insufficient knowledge. A chi-square test was then conducted to evaluate the association between participants’ level of formal education and the knowledge of the opioid overdose education they had received. The level of significance for this test was set at p ≤ 0.05.

Results

A total of 32 OEND sessions were held from July 2020 through February 2023. Of the 1300 participants seen, 91% (1184/1300) were patients who visited one time and 9% (116/1300) were patients who visited more than once resulting in 1453 overall participant interactions. Participants who visited more than once completed 269 visits and averaged 2.3 visits in three years. The number of participants who received OEND decreased yearly from 672 in 2020, 412 in 2021, and 340 in 2022. Only 29 participants received education in January and February of 2023 at the start of the new year.

The average age of participants who received OEND was 40 years old (Table 2). Most participants were between the ages of 35–44 years (35.85%, n = 466/1300). Additionally, participants who accessed OEND were primarily white (67.77%, n = 811/1300) and mostly identified as a man (59.15%, n = 769/1300). Approximately 83% (n = 1082/1300) reported their sexual orientation as heterosexual. Sixty-eight percent (n = 886/1300) of participants resided in Orleans parish and 76.38% (n = 993/1300) had Medicaid/Medicare for insurance. The highest level of education for most participants was high school or some college representing 29% and 20.77% of the participants respectively. More than half (51.46%, 669/1300) of participants who accessed OEND experienced an opioid overdose themselves and most participants (89.00%, n = 1157/1300) witnessed an opioid overdose within the previous 0–3 months (n = 733, 63.30%).

Table 2 Demographic Distribution of OEND Participants (n = 1300)

Among the participants who visited the OEND station more than once, 160 responses were collected for how helpful the previous education session had been. Of these responses, 75% (= 120/160) were “Very helpful”, 3.13% (n = 5/160) found it tolerable, and 21.88% (n = 35/160) did not receive previous education from us. Repeat participants (RPV, n = 122) scored high on their assessment quiz with 58.19% of participants scoring adequate or superior knowledge on the knowledge scale and 67.21% scoring usually and consistently appropriate behavior on the behavior scale (Table 3). There were also 202 one-time visitors (OTV) who were assessed using the knowledge scale. The repeat visitors showed a higher average knowledge score (mean = 3.61) compared to the one time visitors (mean = 3.38).

Table 3 Knowledge and Behavior Assessment Scores for repeat visitors (n = 122)

When assessing associations between the level education and the knowledge scale, the results reveal a chi-square test statistic (χ2) of 7.726 and a p-value of 0.4023, indicating that there is no statistically significant association (Table 4).

Table 4 Contingency Table of Knowledge and Education

Discussion

The OEND program implemented by the pharmacist and student pharmacist at the SSP provided a valuable service to participants during the height of COVID-19 and was well received. Participants who repeated the program retained knowledge and showed a positive change in their behaviors regarding opioid overdose reversal.

Most clients of the SSP participated in the OEND program during the height of the COVID-19 pandemic. This also coincides with some of the largest rates of opioid use signified by the amount of reported opioid overdose deaths and poisonings at that time [2]. Though the standing order for naloxone in Louisiana was established in 2017, naloxone wasn’t available to harm reduction focussed organizations like SSPs until around 2019, just as the pandemic occurred. Thus, it is expected that most SSP participants first participation with an OEND program may have occurred during its early establishment. Of the clients who participated in the OEND sessions, only 18.5% were repeat visitors. This is not surprising, because the city of New Orleans is considered a tourist city, leading to many transient people visiting or living in the area for short periods of time. Also, there was an increase in resources for clients to obtain replacement naloxone city-wide from outside organizations.

The majority of clients who accessed the OEND were cis, white, males-identified at birth and most participants were between the ages of 36–44 years old. This aligns with previous published narratives that focus on the opioid overdose epidemic's effect on white individuals [27, 28]. Despite being located in an underserved community where the primary people who live within the vicinity of the SSP are people of color, the people accessing OEND were predominately white. During this opioid epidemic, black, indigenous, and people of color (BIPOC) are experiencing racial disparities that have negative outcomes [29, 30]. An important barrier to explain why BIPOC may not participate in naloxone education includes mental access barriers such as stigma, fear and mistrust. The fear of racism has shown to amplify mental access barriers due to the perceived risk of race-based mistreatment and negative consequences (i.e. encounters with law enforcement) linked to substance use [29, 31]. Other barriers for accessing HR facilities include, distance or hours of operation, lack of confidentiality of pharmacies, fear of being seen at HR programs, and/or shame [32]. We suspect networks of underserved, hyper-marginalized PWUD in our communities are not receiving care due to access barriers. Strategies are needed to provide harm reduction care that is culturally appropriate and tailored to meet the needs of specific populations that experience barriers to access.

Approximately 50% of participants who received OEND education experienced overdosing themselves. And most of the participants, approximately 90%, witnessed an overdose within the previous 0–3 months. This is not surprising as the participants who likely received OEND education were those with lived experience using drugs. This data reinforces the value and need of OEND programs in SSPs as the clients of these programs are likely to encounter an overdose and use the naloxone that is given to them within a narrow time frame. Additionally, our data suggest that OEND was of benefit to all participants regardless of their highest level of education, further showing value for our program. In particular, the absence of a significant relationship between clients’ knowledge retention and their level of education highlights the accessibility of the program’s material and mode of delivery, suggesting that it effectively facilitates equitable learning opportunities across diverse populations.

Clients of the SSP that participated in the OEND sessions with the pharmacy team largely retained their knowledge regarding opioid overdose reversal over time. Most participants scored adequate or superior knowledge on the knowledge assessment and usually or consistently appropriate behavior on the behavior assessments which were completed on another day after an initial OEND education session. These scores may also be high because the participants who return to the SSP are likely to have more exposure to OEND outside of our program through the SSP. Participants may benefit from receiving OEND as a full session later in their encounters to reinforce learned information and to convey any new tips or changes in overdose protocols. Other reasons for the need to reinforce OEND education may include altered state of consciousness of the participants, a possible inability to pay attention because of the setting, lack of hands-on education due to the social distancing restrictions during the height of COVID-19 protocols, and/or lack of time to engage the entire session. Thus, the majority of clients who participated in the program multiple times still scored the education sessions as helpful.

There are several limitations to this research. The first is that patients provided their patient codes. Participants in our OEND may have provided a participant code using false information. Therefore, we may have had more repeat participants than captured for analysis. Another limitation is that there were several members of the pharmacy team grading the knowledge and behavior assessments. Differences in grading subjectively may have also affected the results. Because of the urgency of providing education, the location, COVID19 restrictions, varying reading levels of clients, we chose to provide the knowledge and behavior assessments verbally and then the results were delivered to the in-take person verbally. Though we were diligent in ensuring the scores went to the correct person, there is still room for human error. Some clients who were seeking OEND were at varying levels of influence or consciousness during the education, which may have affected their comprehension of the education provided. Finally, clients who received OEND may have received education from other locations prior to participating with our program.

Conclusion

OEND programs established at SSPs play an important role in providing education to PWUD and the participants found the education helpful. Participants’ of SSPs may need refresher courses of opioid overdose education periodically. Future research is needed to better investigate which knowledge and behaviors need more emphasis in the OEND session to better tailor these sessions to the needs of certain populations. Additional research is needed to assess education for the use of drug testing supplies. Though naloxone continues to become increasingly available, OEND is an important factor in preventing opioid overdose deaths.