Learning how local teams can cooperate to stop overdoses

NC TraCS researchers are helping local officials and healthcare providers understand how rapid-response teams can prevent overdose deaths.

An opioid overdose is an incredibly dangerous moment—and not only in the initial moments of the overdose.

Even when someone survives an overdose, they face a high risk of suffering from another overdose in the coming days, weeks, and months. One study from Massachusetts, for example, found that patients who came to the emergency room for an opioid overdose had more than a 5% chance of dying in the following year, and most of those people died from another opioid-related overdose.

The riskiest period after an overdose is in the first couple of days afterwards, the study found. But these few days—when a person has just survived an overdose and has been given medical care, maybe even put on medication to help with withdrawal—can also be a "golden window of opportunity" to get these patients onto a different trajectory, says Micha Belden, a senior investigator in the Implementation Science Methods Unit (ISMU) at the North Carolina Translational and Clinical Sciences (NC TraCS) Institute.

Belden and Chris Shea, an implementation researcher at the UNC Gillings School of Global Public Health and co-lead of the ISMU at NC TraCS, are currently leading a study on post-overdose response teams, or PORTs, in North Carolina.

PORTs are local teams, often comprised of some combination of emergency responders, peer recovery support specialists, or other health care providers who try to ensure that people who've suffered from overdoses get the care they need in the immediate aftermath of that overdose. In North Carolina, some of this work has been funded with settlement money from pharmaceutical companies, distributors, and retailers held liable for their role in the opioid epidemic.

According to one study, PORTs may be associated with a reduction in overdose deaths. But different localities have used different approaches to designing and implementing PORTs.

"Not all PORTs look the same. They can include team members performing different roles," Shea says.

The North Carolina Department of Health and Human Services (NC DHHS) suggests that a PORT team includes a mix of people from the community. Frequently, emergency medical services are part of the team, since they're often the ones who arrive first on the scene following an overdose. Sometimes, PORTs include peer support specialists and others who have been through the addiction recovery process themselves.

"Peer support specialists can engage with the individual in a particularly powerful way, because they have lived experience," Belden says. Belden and Shea say that while law enforcement and fire departments haven't been formally a part of the teams they've worked with, PORTs can work closely with both. Other potential stakeholders in a community's PORT ecosystem include hospitals, local public health departments, community groups, and faith groups.

In addition, according to Shea, "PORTs may perform different types of activities related to overdose prevention, overdose response, and ongoing care for those who have experienced overdose." Some will come on scene immediately when an overdose is reported, while others will follow up with the person within the next few days. Many PORTs give out naloxone and other safety supplies to people who overdose and may follow-up persistently for weeks and months. Some will also immediately offer to start a patient on buprenorphine after an overdose, which can help manage withdrawal symptoms and lower the risk of future overdoses—and some PORTs will even help people contend with other challenges as well, like domestic violence or hunger.

Belden and Shea's project is researching how these teams are being implemented across the state. They want to help local officials, first responders, law enforcement, and other stakeholders create and run post-overdose response teams that fit their community's needs and prevent overdose deaths.

This project is focusing on PORTs in four North Carolina counties: Buncombe, Carteret, Wilson, and Alleghany. These counties span the state, from the coast to the western mountains, and differ demographically. Alleghany County, for instance, is a very rural northwestern county with a population around 10,000 and a PORT of two people, while Buncombe County is home to Asheville, the most populous city in western North Carolina, with a PORT of more than a dozen people, including community paramedics, peer support specialists, and mental health clinicians.

"The less established [PORT] teams want to learn how other teams connect and stay connected with clients long-term, meeting their needs, and helping them get to a place where they don't need their services as much."

Because there are so many possible innovative ways of structuring a PORT, people have questions about what the best practices are. With this project, Belden and Shea want to understand how various PORTs have been designed, how they address various challenges in their communities, and what works to prevent overdoses and keep people safe.

"The PORTs that are just getting started want to learn, from beginning to end, what are other PORT teams doing," Shea says. "The less established teams want to learn how other teams connect and stay connected with clients long-term, meeting their needs, and helping them get to a place where they don't need their services as much."

The project is conducting interviews with stakeholders in these counties and having them complete surveys to understand the details of how different PORTs are structured. They're also running focus groups to develop process maps, which are diagrams that can help visualize how PORTs perform specific processes, identify potential barriers, and find solutions to those barriers. In addition, Belden and Shea are participating in a collaborative organized by NC DHHS where PORT members, local officials, and others can learn from each other.

PORTs can face all kinds of challenges. Belden says many of the patients that PORTs work with need mental health support but have little or no health insurance, which can make it hard to find care. In addition, some counties can have trouble retaining paramedics or peer support specialists, which can often be low-paying and high-stress jobs.

But many PORTs, including those with fewer resources, have still been doing incredible work, Belden adds—and the team's research is starting to parse out what can help these teams thrive and succeed. For one, Belden says, having community coalitions and formal agreements between emergency medical services, health departments, hospitals, and other stakeholders seems to be an important way of making sure that everyone is on the same page and knows how to work together to support patients.

"The PORT teams are demonstrating that individuals who use drugs can recover with the appropriate supports."

Simply having these PORTs on the ground may also help to foster cultural changes. "By going out and doing overdose education and naloxone distribution in schools, libraries, shops—all over—they're actually, in many ways reducing stigma," Belden says.

"The PORT teams are demonstrating that individuals who use drugs can recover with the appropriate supports," he adds. "Which is a pretty remarkable thing that we're seeing across the state."

"The PORT teams, the peer support specialists, the behavioral health specialists, the folks from the hospital, the sheriffs and the law enforcement officers, local county officials—it's just really remarkable to me how these coalitions have formed to take these opioid settlement dollars and try to figure out the best way to apply them in their communities and do it in a really transparent way," Belden says. "—it's a thing of beauty."