Naloxone distribution programs in the US are ongoing in Chicago, Baltimore, San Francisco, New Mexico and New York City. Additional community-based organizations interested in minimizing the adverse consequences of drug use in several cities in the US, including Los Angeles, Providence, Pittsburgh and Boston, are in the process of planning and developing naloxone administration programs for drug users. The recommendations presented here are designed to assist other SEPs and health promotion centers in their planning, implementation and evaluation of similar programs for opiate users. We recognize that this is not a formal process evaluation but given the innovative nature of the project and the unusual collaborative and evaluative processes, we feel that there is valuable insight to be gained from the team's experiences with naloxone distribution in NYC over the past two years.
First, take-home naloxone distribution programs for opiate users are feasible and both programmatic experience and data suggests that drug users can be trained to respond to heroin overdose by giving naloxone. The Chicago Recovery Alliance (CRA) has operated one of the largest naloxone distribution programs to date. Since January of 2001, CRA has reported equipping approximately 3,500 people with naloxone, resulting in 319 reversals which were associated with 20% decrease in overdoses in 2001 and a 10% decrease in 2002 and 2003. This reversed a steady increase in heroin overdoses since 1991 . In Baltimore, naloxone distribution began in April 2004; as of March 2006, 951 individuals have been trained in naloxone administration and a reported 131 overdoses have been reversed with the use of naloxone . Since December 2003, through a collaboration between Project DOPE and the San Francisco Department of Public Health, 700 participants have received a prescription for naloxone with 170 reported overdoses reversed with naloxone . Currently in New York City, since April 2005, 1485 people have been trained and received naloxone prescriptions with approximately 104 reported overdose reversals . We caution that all such program evaluations need to be understood within the context of the outcome they are evaluating.
Second, flexibility is essential in the development, implementation and evaluation of naloxone administration programs. This flexibility means adapting overdose prevention training curriculum to be delivered quickly and effectively in numerous settings– whether in a designated room at a SEP with a few participants, or outside in an often chaotic public space during needle exchange sessions. In addition, each SEP requires adaptation of program components to fit participant needs and experiences. A SEP that works with runaway or homeless adolescents considers different programmatic needs and issues than a SEP that attracts an older drug-using population.
Third, evaluation components should be designed for feasibility and simplicity. A brief assessment that can be administered in a few minutes to participants who may be high or unresponsive or at first unwilling to participate is more practical than a detailed questionnaire.
Fourth, the program is entirely dependent on opiate user participation–responding to and incorporating feedback from participants (i.e. multiple outreach strategies, flexible hours for naloxone prescription by the medical physician, an abbreviated training curriculum) is integral for program success.
We recommend that additional cities in the US initiate take-home naloxone programs for drug users because they are feasible and effective; we urge further assessments of new data on participant experience with naloxone and overdose prevention; and we recommend additional systematic evaluations with follow up components. In NYC, drug users at local SEPs continue to be trained in overdose prevention and naloxone administration, an initiative that may be instrumental in reducing overdose mortality in NYC.