Approaches, Barriers, and Facilitators in Statewide Initiative to Combat Opioid Overdose: A Narrative Review of Ohio's Experiences During the HEALing Communities Study.

Objectives: Opioid-associated fatal and non-fatal overdose rates continue to rise. Prehospital overdose education and naloxone distribution (OEND) programs are attractive harm-reduction strategies, as patients who are not transported by EMS after receiving naloxone have limited access to other interventions. This narrative summary describes our experiences with prehospital implementation of evidence-based OEND practices across Ohio as part of the HEALing Communities Study (HCS).

Methods: HCS was a parallel-group, cluster randomized, unblinded, wait-list controlled trial of 67 communities highly impacted by opioid-related overdose fatalities in four states, including Ohio. An EMS Intervention Design Team (IDT), consisting of EMS physicians, paramedics, and an EMS department Chief with an established OEND program, supported participating EMS agencies. Services of the IDT included protocol development, program training, and stigma-reduction education. HCS funding supported implementation costs and varied by county/agency.

Results: In 12 Ohio counties, 29 agencies implemented an OEND program; agencies served rural, suburban, and urban communities. While leaving naloxone kits with patients and/or families at an EMS call was universally adopted, additional OEND approaches were undertaken. Seven EMS agencies registered with the Ohio Department of Health's Project DAWN program, allowing hub-and-spoke distribution of state-provided naloxone to smaller OEND programs. An urban EMS agency targeted mass gatherings for OEND efforts; bicycle teams providing crowd medical response distributed leave-behind naloxone kits in a process mirroring traditional 9-1-1 calls while static first aid stations offered overdose educational materials, information on local resources, and take-home naloxone kits. A rural EMS agency allowed community members to request naloxone kits from agency headquarters. To address an overdose hotspot at an interstate rest area, a rural joint ambulance district partnered with the county health department to install and maintain a public-access naloxone station. Observed facilitators included Ohio's legal and regulatory environment, creating local definitions of success, identifying and empowering local champions, and operational solutions to ease OEND for practitioners. Stigma represents the biggest barrier, with ongoing education as the best solution. Incremental program implementation was most successful.

Conclusions: Our OEND implementation experiences across multiple Ohio EMS agencies identified several barriers, facilitators, and creative solutions that may inform future prehospital harm-reduction programs.