ALBERTA COMMUNITY COUNCIL ON HIV

CBTHN

Alberta continues to experience high numbers of overdoses and deaths association with the illicit use of opioids. The rate of deaths resulting from an opioid overdose has increased since 2014. In 2014, 117 people died from an apparent opioid overdose, in 2015, this rate increased by 110%, to 257 people. In 2016, the apparent opioid drug overdose deaths increased to 343 people, a 33% increase. The Community Based Take Home Naloxone (CBTHN) project was introduced to eight communities in May 2015. Since this start, the numbers of naloxone kits and reported reversals have consistently increased from month to month. The ACCH will continue to facilitate the CBTHN project in eight towns/cities and their surrounding regions across Alberta.

From May 2015 to March 2017, 6,160 kits have been distributed and 1,016 reversals have been reported. The 2016-2017 Interim report found that 1,060 community members and 1,435 candidates received training. It has been reported by all project sites that as Alberta Health Services has increased the number of registered sites distributing naloxone, these eight sites have had increased requests for training for the newly registered site. The CBTHN projects are knowledge hubs and will work in partnership with Alberta Health Services to ensure the registered naloxone distribution sites are well educated and informed. This will include any work beyond this, it will be a collaborative partnership with the goal to support the work. The community organizations provide a distinct perspective on training, through a grassroots lens in a non-medical environment. This training is built from the organizations experience working at the grassroots level in a collaborative environment.

For this project, there are two important aspects to project delivery. The first is the intensity associated with the client support. These services are non-judgmental, client-centered, strength-based services that provide skills, knowledge, resources, and support for people to live safer and healthier lives. Interactions while distributing the kits can include health assessments, mental health checks, STI testing, access to treatment, check-ins, referrals, supportive relationships, access to all the services the site offers, as well as emergency services. Accessing supports in a safe, non-judgmental environment is a key aspect to this project that reduces the harms associated with the use of substances. As one component in a full spectrum of harm reduction services, the CBTHN project includes the meaningful and active involvement of people who use drugs.

The second is the intricacies of the training needed to ensure safe and effective use, for the people who use drugs, for the bystander administrator (individual or business), and agencies that will take on naloxone distribution. Training is also provided on how to address the after effects of an overdose for those involved, physically, mentally, and emotionally. Not only do new sites need to understand how to educate a person in the safe and effective use of naloxone, they must also increase their knowledge regarding harm reduction practices overall to challenge the stigma and discrimination faced by their clients; which may include the registered site’s own discriminatory thoughts and practices. Thus, training is not just how to administer naloxone, it also introduces or enhances a sites knowledge regarding harm reduction practice, and provides a forum to discuss the after effects.

Two positions at each CBTHN project site are required to achieve both aspects of the project in an effective manner. This increase of staffing is the direct result of the increase of work resulting from the increase of registered sites, and the increased involvement of people who use substances, or those who wish to intervene as a bystander administrator. The two positions will be made up of registered nurses and outreach/facilitation staff. The registered nurse will be responsible for the onsite client interaction and support, as well as training and supporting the outreach/facilitation staff person. The outreach/facilitation/navigation staff member will work outside of the organization for the most part to provide training to new registered sites, as well as to those who wish to have naloxone onsite to reduce the risk of opioid overdose. The registered nurse will attend and support the outreach/facilitation staff member where deemed appropriate and when the complexity related to the site becomes apparent.

Project reach will extend past city limits into determined catchment’s area. Work will be done to cover Alberta, with no overlaps in regions.

The project intent is as one component in a full spectrum of harm reduction service, the CBTHN projects will provide resources, knowledge, and support to Albertans at risk for overdose services to lead safer and healthier lives.

Objectives

a. To distribute a total of 4000 naloxone kits by May 30, 2018
b. To increase the total number of reported reversals to 1000 by April 31, 2018
c. To increase public knowledge regarding naloxone access and use
d. To debrief people who have used naloxone.
e. To provide training to 80 new community agencies, registered naloxone distribution sites, and/or local business.
f. To provide training to individuals to use intramuscular naloxone
g. To provide supportive resources to reduce harm, and improve individual health
h. To provide trauma intervention and counselling to individuals accessing services
i. To provide supportive resources to employees engaged in naloxone distribution and client support

Project Components and Role of ACCH

a. To hold the grant agreement with Alberta health for ACCH member CBTHN projects and disperse funds as necessary (per disbursement schedule),
b. To provide member organizations with the approved work plan template,
c. To complete reporting requirements to Alberta Health,
d. Operationalize a coordinated sector response to naloxone by creating an ACCH Naloxone Strategy.
e. To support members in being hubs;
f. To support member organizations in their work, and
g. To provide roll up on data collection.

Role of the Member Organizations

a. Opioid overdose response and prevention training for the individual,
b. Opioid overdose response and prevention training for staff at organizations, businesses, and community members (including train the trainer),
c. Opioid overdose response and prevention training for the community,
d. Distribution of naloxone kits to people who self-identify as needing one,
e. Support and outreach to newly registered distribution sites,
f. Support and outreach to organizations, businesses, and schools,
g. Mental health supports and referrals are provided to the individual
h. Health assessments are provided to the individual, including STI testing and treatment referrals,
i. To build and enhance new and existing relationships, to work with an individual, their social network, and their community one-on-one, and
j. Data collection and reporting.

Outcomes

Short Term
a. Service providers are knowledgeable about Harm Reduction
b. Individuals access broader support networks and reduce isolation
c. Individuals access health care supports
d. Individuals access mental health supports
e. Individuals choose to take a STI test

Medium Term
a. All service points provide non-judgmental and user friendly services
b. Individuals receive the health care support they need and request
c. Individuals receive the mental health support they need and request
d. Individuals access treatment services

Long Term
a. People who use drugs are an integral part of the larger community
b. Decreased costs to health care, social service, education, and justice systems
c. Decreased stigma and discrimination

Project Focus Areas

Addiction Services: Current evidence shows that increased access to naloxone can lead to fewer overdose related deaths, and increased provision of medical and social support to vulnerable individuals.

Indigenous People: All community agencies participating in this project provide services to Indigenous people.

Children, Youth and Family: Harm Reduction activities indirectly and directly support children, youth and families.

Multiple and Complex Needs: Individuals with multiple needs currently and will continue to access the CBTHN projects. These community agencies can provide a multitude of supports in one location.

Evidence-base

Naloxone is a safe and effective medication that can reverse the effects of opioid overdose. The province of Alberta uses the intramuscular injected naloxone, with only a few places using intranasal naloxone. There is evidence that naloxone projects contribute to a reduction in overdose related mortality.

Alberta Health Services is currently working on a Take Home Naloxone Kit program evaluation, which the ACCH and member organizations are participating in. The purpose is to establish a more complete understanding of the impact of take home naloxone distribution across the province. This study will be the first for Alberta, and an essential measure of success in project delivery.

Prior to the completion of this evaluation, work done outside of Alberta consistently demonstrates the positive impacts and changes associated with naloxone distribution through community organizations. Benefits shown in several evaluations demonstrate a marked increase in knowledge, and increased STI testing. Although it is difficult to measure the impact of community based naloxone projects, it has been shown in several studies that individuals nearly always survive at the first response stage when receiving bystander administration. Looking at the data collected generally in Alberta, the highest numbers of reported reversals are occurring through the CBTHN projects. People are returning to the CBTHN projects to take new naloxone kits and connect to the services available there. This demonstrates the assertions that community based organizations are creating opportunities for individuals beyond naloxone kits to access health, mental health, and other supportive services.

The data in Alberta collected by ACCH demonstrates that reported reversals are increasing. This could be due to three reasons, first, as community organizations build trusting relationships, individuals return. The second is that more people are utilizing naloxone and returning to replace a used kit. Third, kits are more important because people are not calling 911 for the most part. These three reasons demonstrate how naloxone saves lives in Alberta.

In the month of February 2017, Alberta Health Services distributed a total of 3000 naloxone kits from 1039 registered sites. 21% of these kits were from ACCH member CBTHN project sites; which means 0.77% of the total sites are providing 21% of the total kits.

The CBTHN projects started in May 2015 and in the first year of project delivery, the ACCH member organizations distributed 2,088 kits. In year two of the CBTHN project, up to March 31, 2017, there were 4,072 kits distributed. As this project has continued to roll out there has been a steady increase of kit distribution and reported reversals. With the current rate of distribution, by May 2017, the distribution will double from the prior year. In year one, sites reported 216 reversals. As of March 2017, the sites have reported 800 reversals, an increase of 270% from year one. If the current trend of 100 plus monthly reported reversals continues, by May 2017, the total increase will be over 300% from year one.

Consistently, the member organizations delivering CBTHN are recognized as experts, and receive training requests from other agencies. The distribution of naloxone goes beyond the ability to recognize an overdose and the actual injection. The emotional, physical, and mental impacts of witnessing an overdose, or going through an overdose require more training to manage, support, and connect the people involved to other services to reduce harm.

Key Benefits

Coordinated approaches to community based take home naloxone projects and training support in the province of Alberta.

The goals of CBTHN are to:

  • Reduce health risks associated with drug use;
  • Improve access to health and social services for marginalized population;
  • Facilitate connections to treatment and enhance health behaviours
  • Contribute to the safety and quality of life of communities
  • Reduce stigma and discrimination related to drug use
  • Educate Albertans on Harm Reduction

Data Collection

Each organization will report the following to the ACCH:

  • Number of kits dispensed
  • Number of individuals trained
  • Hours of training provided
  • Number of kits that were used/lost/expired
  • Number of reported reversals
  • Challenges and successes

Project Sites

The ACCH member organizations eligible to undertake the CBTHN project are:

  • HIV North Society
  • HIV West Yellowhead
  • Turning Point
  • HIV Community Link
  • Streetworks
  • Safeworks
  • ARCHES