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Implementing Harm Reduction Initiatives to Address the Opioid Crisis: Learning from Stakeholders in Three North Carolina Counties Nedra Cox (Guilford County DHHS Public Health), Victor Hough (Buncombe County Health & Human Services), Savannah Kent (Buncombe County Health & Human Services) and Lauren Wood, MS (formerly Haywood County Health & Human Services Agency)IntroductionIn July 2017, in response to the increasing death and despair associated with the opioid epidemic in North Carolina, the NC Department of Health & Human Services (DHHS) released its comprehensive Opioid Action Plan. Its seven strategic aims were to 1) create a coordinated infrastructure; 2) reduce oversupply of prescription opioids; 3) reduce diversion of prescription drugs and flow of illicit drugs; 4) increase community awareness and prevention; 5) make naloxone widely available and link overdose survivors to care; 6) expand treatment and recovery oriented systems of care, and; 7) measure impact and revise strategies based on results (NC DHHS, 2017). DHHS proceeded to fund and support local and statewide initiatives to tackle the plan’s aims. In August 2018, DHHS released a Centers for Disease Control & Prevention funded grant, Emergency Overdose: Local Mitigation to the Opioid Crisis for Local Health Departments/Districts, for public health departments to apply for up to $100,000 to implement high-impact strategies at the community level to address the Action Plan’s fifth strategic aim. The potential harm reduction strategies selected by applicants from the available options were: developing post-overdose outreach teams, creating or expanding syringe exchange programs, and linking justice-involved persons to care. Buncombe County Health & Human Services (BCHHS), Guilford County Department of Health & Human Services Public Health Division (GCDHHS) and Haywood County Health & Human Services Agency (HCHHSA) were three of the 18 grant recipients funded from November 2018 through August 2019. BCHHS aimed to implement a syringe exchange in its facility; GCHHS to expand post-overdose outreach and syringe exchange and provide support to justice-involved persons; and HCHHSA to implement post-overdose outreach. BCHHS utilized its funding directly, whereas GCDHHS passed through its funding to UNC-Greensboro Guilford County Solutions to the Opioid Problem (GCSTOP) harm reduction program, and HCHHSA both utilized funds directly and contracted with NC Harm Reduction Coalition (NCHRC).This project aims to learn from the grant-related efforts in these counties from key stakeholders. We hope to provide lessons learned or possible guidance to communities considering harm reduction strategies to combat the opioid crisis. A program evaluation of each grant is beyond the scope of this project and will be conducted by NC DHHS. What is Harm Reduction and why is it an “environmental” topic?Harm reduction programs focus on promoting policies and practices that address the adverse effects of drug use including overdose, HIV, hepatitis C, addiction, and incarceration (NCHRC, 2019). Methods include but are not limited to condom distribution, access to sterile syringes and disposal, medications for opioid dependence such as methadone and buprenorphine, and overdose prevention through naloxone distribution (NCHRC, 2019). Beyond the logistics, harm reduction is also a “social justice movement built on a belief in, and respect for, the rights of people who use drugs” (Harm Reduction Coalition, 2019). Multiple peer-reviewed scientific research articles document that established community-based, participant-led syringe access programs/harm reduction organizations successfully reduce disease transmission; increase substance users’ engagement with health care, including substance use treatment; and increase substance users’ referrals to other community services (Hagan et al., 2000; Hagan et al., 2001; Nadelmann & LaSalle; 2017 and Wallace et al., 2018). Community based harm reduction work is relevant to both the social and physical environments. With its focus on preventing death, lowering infectious disease risk throughout a community, or preventing syringe-related injury to law enforcement officers, first responders and other community members by providing safe disposal of injection equipment, it is an environmental topic. Socially, harm reduction work also aims to create a less judgmental community dialogue around drug use and combat stigma. It may seek to bring drug users out of the margins and more into the mainstream by linking them to various public health, medical and behavioral health and community-oriented services. MethodsThe methods of this project included a review of publicly available, county-level quantitative data; online surveys with key stakeholders in each county; and interviews with grant and harm reduction staff. Review of Publicly Available Quantitative dataThe North Carolina Opioid Dashboard contains data on 13 key metrics reflecting progress on the 2017 Opioid Action Plan. Freely accessible online, it contains state- and county-level data and was reviewed by the group to establish a shared understanding of the opioid and harm reduction context in each county. Several of the metrics relate to the supply and trafficking of opioids and medical treatment. The four key metrics considered to be most relevant to the harm reduction initiatives are: unintentional opioid-related deaths, opioid overdose ED visits, EMS Naloxone Administrations and community overdose reversals (NC Opioid Dashboard, 2019). Key Informant Surveys & InterviewsGroup members performed a stakeholder analysis for each county to determine key informants whose input would be important based on their leadership and involvement in addressing the opioid crisis and the grants. The list of stakeholders included public health staff leading or administering the grants, harm reduction staff, HHS and public health directors and staff, local medical and behavioral health leadership, emergency management and law enforcement leadership, representatives of research and/or educational institutions, and substance use coalition leads or key members (see Appendix 1). Group members then developed a 10-question survey via online survey tool Survey Monkey inquiring about stakeholders’ opinions about harm reduction and the DHHS grants (see Appendix 2). The survey, with an explanation of its purpose and context, was emailed to 77 key informants in the three counties in early July 2019. Recipients were given two weeks to respond and were sent one email reminder. The final survey question inquired whether the respondent would be willing to be interviewed. Project members interviewed a selection of those willing to be interviewed to elaborate on responses, prioritizing grant leads and local harm reduction staff to gain a richer understanding from the stakeholders directly involved with the grant projects. Results & DiscussionOpioid DashboardThe key metrics for Buncombe, Guilford and Haywood Counties from the online Opioid Dashboard as discussed above are shown in Table 1. The data is updated quarterly and was compiled for this table for 2018, the most recent full year of data. Rates per 100,000 people were calculated for easier comparison. Table 1. Key Opioid Dashboard Metrics for Buncombe, Guilford and Haywood Counties & NCBuncombe County(pop. 257,607)Guilford County(pop. 526,953) Haywood County(pop. 61,084)North Carolina(pop. 10,273,419)Indicator Actual(2018)Rate per 100,000Actual(2018)Rate per 100,000Actual(2018)Rate per 100,000 Actual(2018)Rate per 100,000# Overdose deaths67 26.087 16.513 21.31,619 15.8# ED visits265 102.9318 60.378127.76,769 65.9# EMS Naloxone Administration401 155.7841 159.6105 171.912,237119.1# Community Naloxone reversals302117.2179 34.097 158.83,94338.4Overdose death rates in all three counties are higher than the state rate, especially in Buncombe County, reflective of a serious opioid crisis warranting state grant funding. Similarly, EMS Naloxone administration rates were higher in all three counties than for the state as a whole, clearly demonstrating the scale of the opioid overdoses requiring response in the three counties. For opioid-related emergency department visits, the rates were much higher in Haywood and Buncombe Counties (127.7 and 102.9 per 100,000 people, respectively) than for the state (65.9 per 10,000 people). This result is similar for community Naloxone reversals, the number of overdoses reversed by community members administering Naloxone. In Guilford County this rate is lower than that of the state; but in Haywood and Buncombe Counties they are several times the state rate (117.2 and 158.8 per 100,000 versus 38.4 per 100,000, respectively). This reflects concerted efforts by Haywood and Buncombe County public health and harm reduction organizations to distribute Naloxone to community members, train them to administer it and encourage reporting of its administration. Surveys & Interviews Survey results for yes/no questions were calculated by Survey Monkey. Free-text responses were downloaded into an Excel spreadsheet and analyzed by group members per the results below. RespondentsThe overall survey response rate within the requested time frame was 55%. Of 42 respondents who completed the survey, there were 20 from Guilford County (47.3% of total), 13 from Haywood County (31% of total), and nine from Buncombe County (21.4% of total). Figure 1 illustrates the respondents by category of agency they represented. Figure 1. Awareness of Grant Upon establishing respondents’ roles in addressing the opioid crisis in their counties, a subsequent survey question inquired about their level of awareness of their county’s grant. Of the 42 respondents, 37 (88.1%) were aware of the grant having been received by their local health and human services agency; 5 (11.9%) were not aware. Respondents who were not aware of the grant were mostly representatives of educational institutions and less likely to be directly involved in harm reduction work. Perceptions of Grant Respondents were then asked to share their perception of the harm reduction grant work being done in their county. These free-text responses were coded positive if entirely positive or positive with one non-critical suggestion or comment; critical if they included any critical comments or suggestions; and unaware if the response expressed a lack of familiarity with the work. Overall, 64% of respondents expressed a positive perception of the grant work and approximately 15% expressed some criticism of the work; over 20% were unaware of the specific work being done. Suggestions or critiques offered in the perception responses generally communicated the following: 1) The community needs better communication about this work; 2) It is difficult to collaborate and gain institutional buy-in to implement harm reduction work, especially as a government agency; and 3) The community should address the root causes of addiction and prevention more than on harm reduction. The need for better communication was reflected by 11.9% of respondents not knowing their local public health agency had received this grant and over 20% of respondents not being able to share meaningful perceptions of the projects. Respondents in all three counties stated that they didn’t know specifics or wanted more information. The Haywood County grant lead reported that some activities, such as monthly Naloxone distribution and training, were well publicized with monthly flyers, Facebook posts and press releases; but others (specifically, a syringe exchange hosted at the health department) were advertised only by word of mouth and not publicly due to fear of pushback from county leadership. Results from this survey demonstrate a generally positive perception of harm reduction work that would support increased information, education and publicity within the communities. Respondents who reported positive and critical perceptions of the grant work acknowledged that it is difficult to implement harm reduction, particularly for a government agency. All Buncombe County respondents involved in this grant reported the difficulty in getting institutional buy-in for implementing the grant, strengthening the necessary partnerships from law enforcement, EMS and others, and a resulting delay or slow pace in work. Haywood County grant staff also noted that with a 10-month grant period, there was limited time to gain necessary County Commissioners approval, start new projects, hire new staff, and order supplies, leaving more limited time for project implementation. In Guilford County, the Public Health Division avoided potential resistance by allocating all grant funds to UNCG’s existing harm reduction program, GCSTOP. Across all three counties, respondents also emphasized the need to solve the root causes of addiction and focus on prevention more than on harm reduction. Said a Haywood County leader: “They are having an impact on mortality but not on the epidemic. Prevention aimed at youth is at best minimal.” Others, in Guilford County in particular, advocated a focus on the structural roots of addiction and mental health concerns, including institutional racism, poverty and incarceration. Next Steps After inquiring about respondents’ awareness and perceptions of the projects, the next survey question informed respondents that the grants were due to end in August 2019 and asked them to suggest appropriate next steps. The most common response was to find a way to continue the project activities. Other responses included improving education and training of providers, general public and law enforcement. Assessing and evaluating the projects were also common responses; fortunately, a formal NC DHHS evaluation is ongoing. Anticipated BarriersRespondents were also asked to speculate on anticipated barriers to continuing this work in their county. Free-text responses fell into five main types of barriers: 1) insufficient funding; 2) stigma toward drug users or resistance to harm reduction work; 3) lack of education, data or research; 4) inadequate resources or policies; and 5) collaboration. Figure 2 reflects the barriers most frequently cited. Figure 2. Funding was cited as a barrier by more than half of respondents. Considering the continuum of services needing to be funded to address the opioid crisis (including primary prevention, treatment, harm reduction and recovery), prioritization of funding for harm reduction work is a valid concern. Stigma toward drug users and/or resistance to harm reduction work was the second most cited barrier, after funding. This was reflected by comments noting “negative perceptions of and attitudes towards those who are caught in the cycles of addiction, poverty and homelessness” (per one Haywood County community based organization leader). Another leader in Guilford County stated, “Stigma is one of the biggest barriers. Sadly, many people don’t think those with addiction are worth saving and helping”. Barriers related to negative attitudes toward drug users or harm reduction strategies were cited by 21 respondents in all three counties but were most often stated by respondents in Haywood County (9 of 13 respondents). The three representatives of law enforcement and emergency management who responded to the survey were all supportive of the work, but this is not always the norm. The law enforcement mandate to prosecute drug trafficking and the harm reduction philosophy of supporting drug users can be in conflict; and engaging emergency management in becoming more involved in post-overdose outreach can pose a challenge to its already heavy workload. The need for more education, data, or research was expressed by multiple stakeholders across the three counties. Respondents from academia felt that access to research funding and better data was needed, and needed better translation to the community. Other respondents, also in all three counties, felt that law enforcement and emergency management need to be better equipped with an understanding of harm reduction, or re-training on statute and procedures, to allow them to better support it. A media representative expressed that “until people are made to understand the role the entire community plays in widespread recovery, anything else is just a partial solution”.Respondents acknowledged the limited nature of other needed resources besides funding, including supportive policies, sufficient volunteers and access to related services, such as behavioral health services and substance use or hepatitis treatment. There can be stark differences between rural and urban counties in terms of social context and access to treatment, syringe exchanges and behavioral health resources. Buncombe, Guilford and Haywood counties differ in size and access to resources but all have to contend with allocating funding to all necessary resources. Experts advise considering socio‐cultural context and economic disparities in settings with constrained choices or availability of harm reduction services in designing programs (Lancaster et al., 2018). The need for or lack of institutional collaboration was another consideration directly raised in the context of this grant. As noted by an emergency management/law enforcement representative in Guilford County: “this is powerful work that needs to be shared with other entities, both public health and public safety.” Having health departments partner appropriately with existing harm reduction organizations was a key message resulting from this project. This was reflected most directly by a comment in Buncombe County: “I don't believe it makes much sense for state funding to be funneled into HHS based [syringe] exchanges when CBO exchanges already have relationships with folks using drugs, have experience doing the work, make better use of funds, and are more nimble”.LimitationsThe limitations of this study are related to the time and capacity of group members to devote to the design, implementation and analysis of an extracurricular project. In-depth interviews with each respondent would have been ideal, rather than just with public health and harm reduction staff involved in the grants, but were impossible due to time constraints. An expanded stakeholder analysis including project participants would have been ideal. Also, initial attempts to engage NC DHHS staff in this project to expand the stakeholder pool were met with limited communication. More experience with qualitative data methods could have provided additional and more nuanced information from the quite detailed survey responses. Finally, a program evaluation of the grants, beyond the scope of this project, is being conducted by NCDHHS, and we look forward to learning from that effort. ConclusionsThis project aimed to learn from the DHHS grant-related efforts in three NC counties from a group of key informants with the hope of providing lessons learned or considerations to communities considering harm reduction strategies. A key lesson learned was that all stakeholders felt harm reduction had an appropriate role to play in addressing the opioid crisis in their counties. The most common next step recommended in the three counties was to find ways to continue the harm reduction work. Adequate funding and related resources, stigma and lack of communication were acknowledged as key barriers to the success and sustainability of the projects. It is our stance that all of these identified barriers could be overcome with appropriate collaboration, cooperation and shared learning between relevant sectors. Stigma toward drug users, a barrier identified in all counties, must be thoughtfully addressed to make progress on the opioid crisis. As stated by a harm reduction professional in Buncombe County: “What is the matter with us? Why are we so judgmental of those who use drugs other than alcohol or cigarettes?” This stigma may be overcome to some degree by engaging many agencies and individuals in social and public health efforts. More information and interaction among the community at large might help both educate and allow for increased acceptance. Besides funding for harm reduction activities, access to related resources and supportive policies is key. This is true for all three counties. Organizations in Haywood and Buncombe County have both recently applied for sizeable grants from the national Harm Reduction Coalition to increase access to hepatitis treatment in both counties following implementation of these harm reduction grants. The data shows that these NC counties remain entrenched in an opioid crisis with many factors to address. Community-based harm reduction work has been shown to be highly effective at reducing disease transmission and engaging drug users in health care and community-based services. Based on the findings of this study, we feel that barriers may be reduced by coordinated collaboration between organizations implementing work to which they are best suited. Health departments can make important contributions to harm reduction work, including collecting and sharing data and research findings, leading community collaborative efforts, and providing key public health services. But considering the barriers faced by health departments in directly implementing these grants, it may be most effective to partner with community based harm reduction organizations to implement harm reduction services in NC, and to involve all stakeholders in local areas to ensure efforts are sustained. ReferencesHagan H, McGough JP, Thiede H, Hopkins S, Duchin J, Alexander ER. Reduced injection frequency and increased entry and retention in drug treatment associated with needle-exchange participation in Seattle drug injectors. J Subst Abuse Treat. 2000;19(3):247-252. doi:10.1016/S0740- 5472(00)00104-5 Hagan H, Thiede H, Weiss NS, Hopkins SG, Duchin JS, Alexander ER. Sharing of drug preparation equipment as a risk factor for hepatitis C. Am J Public Health. 2001;91(1):42. Harm Reduction Coalition. Principles of Harm Reduction. Accessed on 8/2/19: Lancaster KE, Malvestutto CD, Miller WC, Go VF. Commentary on Fraser et al. (2018): Evidence base for harm reduction services-the urban-rural divide. Addiction. 2018;113(1):183-184. doi:10.1111/add.14052Nadelmann E, LaSalle L. Two steps forward, one step back: current harm reduction policy and politics in the United States. Harm Reduct J. 2017;14(1):37. doi:10.1186/s12954-017-0157-y NC Department of Health & Human Services. DHHS Announces Grants to local Health Departments to Address the Opioid Crisis with Community-Driven Strategies. October 31, 2018. Available: NC Department of Health & Human Services. Opioid Action Plan. 2017. Accessed on 8/2/19 at: NC Department of Health & Human Services. Opioid Dashboard. Last accessed on 8/23/19 at: Harm Reduction Coalition. What Is Harm Reduction? 2019. B, Barber K, Pauly BB. Sheltering risks: Implementation of harm reduction in homeless shelters during an overdose emergency. Int J Drug Policy. 2018;53:83-89. doi:10.1016/j.drugpo.2017.12.011 AppendicesAppendix 1. Stakeholders Included for Surveys in Buncombe, Guilford & Haywood CountiesStakeholders Included per CountyRationale for inclusion in surveyPrimary contacts for opioid grantsMost directly involved leadership/implementation of grants Harm Reduction OrganizationDirectly involved in leadership/implementation of grantsPublic Health Director &Medical DirectorKey leadership of health departments (direct grant recipients)HHS Director (if applicable)Oversees public health and human services in 3 consolidated agenciesChair of BOH/HHS BoardKey county-level public health leadership and governanceCounty CommissionerCounty-level leadership; approval required for grantsCounty Sheriff and/or Sheriff’s Office Public Information OfficerKey county-level Law enforcement leader and/or spokesperson for opioid crisis enforcementCounty Emergency Medical ServicesKey leader for county EMS systems and opioid responseTown/City Police DeptKey municipal law enforcement leader for opioid crisis Community Substance Use (SU) CoalitionKey partners in community-level action addressing opioid crisis in each countyBehavioral Health organization representativesKey partners implementing behavioral health services and treatment effortsAcademic Researchers Key sources of research, evidence base for harm reductionMediaKey source of community-level information regarding opioid crisisSchool System (Superintendent or school board)Key local leaders responsible for issues relating to youth/children/families Appendix 2. Harm Reduction Key Informant Survey Questions1. What is your name, title and the name of your organization? 2. Please summarize your current or most recent role and responsibilities in addressing the opioid addiction crisis.3. Please describe your role or involvement in supporting or implementing harm reduction strategies related to the opioid addiction crisis. 4. In your opinion, what is the appropriate role of harm reduction (e.g. Naloxone distribution, post-overdose outreach, syringe exchange programs) in addressing the opioid addiction crisis? 5. Are you aware that your county health department/HHSA received and is implementing a harm reduction grant funded by NC DHHS to implement innovative harm reduction initiatives in your county? YesNo6. What is your perception of the work being conducted as part of the NC DHHS grant in your county?Buncombe: Implement Syringe Exchange ProgramHaywood: Implement Post-Overdose Outreach Program Guilford: Expand Post-Overdose Outreach & Syringe Exchange, Support to Justice Involved Persons 7. The NC DHHS grant ends 8/2019. What would you consider to be appropriate next steps to address the opioid addiction crisis? 8. What barriers would you anticipate continuing this work in your county? 9. Any additional thoughts/comments? 10. Would you be willing to participate in a brief follow-up interview/call? If so, you will be contacted by one of the group project members. YesNo ................
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