When Massachusetts received its second federal prevention infrastructure grant, state officials anticipated using the money to fight underage drinking, drunk driving, or tobacco use.
However, a thorough assessment of public health data revealed that opiate drugs, such as heroin, morphine, and oxycodone, kill three times more people in the state than do drunk drivers. In fact, between 2004 and 2006, nearly 1,600 people died in Massachusetts of an opioid-related overdose, compared with about 530 deaths in alcohol-related car crashes.
“When we looked at the data on substance use, the trend line for opioid-related deaths was amazing; it had been going up steadily since the 1990s,” says Steve Keel, Director of Prevention Services at the state Bureau of Substance Abuse Services.
Data also showed that opioid overdose occurs in all communities across the state—rural, urban, rich, poor—and among all age groups and ethnicities. In addition, the increasing availability of prescription opioid painkillers, such as OxyContin, Percocet, and Vicodin, contributes dramatically to the problem, both by causing addiction and by offering easy access, with abusers able to obtain drugs from friends, family members, or medical providers.
To try to stem this growing overdose crisis, the Massachusetts Governor’s Interagency Council on Substance Abuse and Prevention, which includes top officials from numerous state agencies, selected the reduction of unintentional fatal and non-fatal opioid overdose as the priority for the state’s Strategic Prevention Framework State Infrastructure Grant (SPF SIG), awarded in 2006 by the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Center for Substance Abuse Prevention (CSAP). The SPF SIG provides $10.5 million over five years to States and Tribal entities to help build prevention capacity and infrastructure and reduce substance abuse-related problems in local communities.
Massachusetts’ SPF SIG initiative, known as MassCALL2, currently funds 15 communities – four in Boston. Funded communities had to demonstrate a need for the prevention help, as indicated by a three-year average annual minimum of 30 opioid overdoses, and a commitment to applying the five steps of the SPF process: assessment, capacity building, planning, implementation, and evaluation. In addition, all funding of local initiatives has to go through the town or city government. The state included this requirement to ensure municipal participation and to leverage sustainability at the end of the grant. To date, this strategy has been a success, resulting in major participation by municipalities.
MassCALL2 also requires funded communities to implement evidence-based environmental strategies to tackle opioid overdose. Environmental prevention strategies seek to change the community context in which substance abuse occurs, focusing on substance availability, norms, policies, and regulations, rather than individual behavior change. Initially, however, the state had difficulty identifying environmental strategies the communities could utilize. When Massachusetts started the initiative, SAMHSA’s National Registry of Evidence-Based Programs and Practices—an online database of proven prevention programs and practices—offered nothing that addressed opioid overdose prevention, Keel says.
As a result, the MassCALL2 management team, made up of Keel, the project coordinators, the project evaluators and the Director of the Governor’s Interagency Council, worked with consultants at SAMHSA’s Collaborative for the Application of Prevention Technology (CAPT) to undertake their own research into effective strategies.
Together, they conducted a literature review, interviewed researchers active in the field, and developed a list of evidence-based overdose prevention environmental strategies from which the funded communities could choose. Strategies included: working with doctors and families to improve awareness of opioid painkillers’ dangerous interactions with other drugs or alcohol; working with and training users and family members to call 911 when an overdose occurs and conduct rescue breathing until help arrives; training police officers to understand that the use of nasal Narcan, an emergency medication that reverses the physical effects of an opioid overdose, can save lives; educating incarcerated former users about overdose prevention and effective response to overdose; and advocating for public policies to reduce barriers to overdose prevention, such as Good Samaritan Laws that protect people reporting an opioid overdose from criminal prosecution for drug possession.
With the local prevention efforts underway for just about two years, the impact of MassCALL2 on overdose rates is not yet clear, Keel says. However, several funded communities report policy changes within public safety departments and correctional institutions, improved public understanding of opiate addiction, and increased use of nasal Narcan to reverse overdoses and save lives. Though not one of the specific strategies of the MassCALL2 grant, prescription medication “take back” programs, which teach residents about proper medication storage and disposal, have been conducted by many communities as well. To keep the momentum going, Massachusetts has applied to CSAP for a no- cost extension of the program for one more year.
“Prescription opioid drug abuse affects individuals and families throughout the entire State, regardless of race, ethnicity, income, or place of residence—urban, suburban or rural,” Keel says. “More people need to understand addiction as a disease—not a moral issue—and as something that can happen to anyone. Addiction can be prevented and is something from which people can and do recover.”