By: Maya Doe-Simkins and Eliza Wheeler of Remedy Alliance
Prevention Point Pittsburgh started distributing naloxone in 2005, after being inspired by formative work by the Chicago Recovery Alliance. Previously naloxone had been used exclusively in hospitals for managing anesthesia and by pre-hospital emergency medical service providers to reverse opioid overdose.
In 1996, fueled by rising fatal heroin overdose among participants and staff, the Chicago Recovery Alliance [30] began distributing naloxone via their syringe services program to people who use drugs and their immediate social networks, an innovation marking the first known formal overdose education and naloxone distribution program in the world [31,32].
For the first decade of operations, the naloxone distribution program at Prevention Point Pittsburgh operated within a broader national context, which evolved from an environment of little support to codified scientific and legal protections.
Given limited funding during the first 18 years (1996–2014) of broader intervention evolution, the development and implementation of new naloxone distribution initiatives within syringe services programs nationally was primarily through peer-based mentoring and technical assistance between programs.
This was the case with Prevention Point Pittsburgh. Naloxone was purchased using smaller value unrestricted funds from sources such as t-shirt sales and donations to memorial funds from families who had lost a loved one to overdose. The staff time and cost to implement and deliver the services was absorbed by syringe service programs, viewed as an ethical imperative regardless of funding.
Using this unfunded interorganizational mentoring model, there were 48 programs in the US by 2010 [18], and 140 by 2014 [33]. Because naloxone was a prescription medication, these initiatives existed in a medico-legal gray area that generated onerous requirements on harm reduction programs. For example, from 2005 to 2014, a documented in-person medical encounter and individual prescription from a physician was required for Prevention Point Pittsburgh to dispense naloxone to a participant.
After coordinated national advocacy by public health organizations, state level legislation, and accumulating scientific evidence, policies supporting naloxone distribution were established starting around 2014 nationally, and directly contributed to the expansion of the naloxone distribution initiative in Pittsburgh.
The advent of federal support for naloxone distribution also had an impact on Prevention Point Pittsburgh by creating an expanded community of harm reduction practice for innovation, diffusion, and communication. In 2014, a memo from the Substance Abuse and Mental Health Services Administration (SAMHSA) to the National Association of State and Territorial AIDS Directors (NASTAD) clarified that using federal funds for naloxone was an acceptable expenditure for state block grants [34]. The first new federal funding that explicitly allowed for naloxone distribution was the Health Resources and Services Administration (HRSA) 2015 Rural Opioid Overdose Reversal grant program [35].
Prior to federal funding, local governments and harm reduction programs used local and philanthropic funds to support naloxone distribution in Massachusetts [20], New York [14], New Mexico [36], San Francisco [37], Rhode Island [38], North Carolina [21], Baltimore [39], and Pittsburgh [19]. Prevention Point Pittsburgh operated within this community of practice, the activity of which centered around the listserv and monthly meetings of the Opioid Safety and Naloxone Network, facilitated for over a decade by co-author AB [40,41].
By the end of 2015, several key events paved the way for further development of Prevention Point Pittsburgh’s naloxone distribution program. Research emerged confirming that naloxone distribution via syringe services programs was effective at reducing overdose mortality [42] and was cost-effective [43,44]. Laws were passed in 43 states to support expansion [45,46]. Two new branded naloxone products (nasal spray and auto-injector) were approved for prescription use among lay persons [47] and heavily promoted by pharmaceutical manufacturers [48].
Harm reduction programs also created a Buyers Club to obtain low cost injectable naloxone directly from a different manufacturer [40]. The FDA supported development of nonprescription naloxone formulations by conducting studies of labeling instructions [49] and expediting review of new products [50].
Of direct relevance to Prevention Point Pittsburgh, Pennsylvania Act 139 was enacted on November 30, 2014, allowing standing orders and third-party naloxone prescriptions. Prevention Point Pittsburgh’s Medical Director issued a standing order for the organization, enabling naloxone distribution without requiring individual prescriptions.