Today, Boston, Massachusetts is considered one of the leaders in teaching laypeople how to prevent and respond to overdoses. Political and financial support from the government allows for a widespread and comprehensive program, which includes naloxone distribution not only at harm reduction organizations, but also at methadone clinics, homeless shelters, inpatient detoxification programs, community meetings, other outpatient and residential addiction treatment programs, emergency departments, and home visits.
Underground naloxone distribution
But things weren’t always so easy in Boston. Less than a decade ago, drug use and overdose were growing – and visible – problems in the city, but there was little interest by city officials in adopting what was seen as a controversial and untested intervention. Activists began distributing naloxone through underground needle exchange programs, without official approval or oversight from a medical professional. As they distributed naloxone, they kept informal records of the number of vials dispersed, and the number of overdose reversals reported. “One of the most important things we did was keep statistics about reversals. Every time someone came back to us and said they’d saved a friend, we recorded it down,” recalls Holly Bradford, one of the people involved in early naloxone distribution.
Eliza Wheeler, who worked at the local needle exchange at that time, remembers that collecting this basic data was not an impediment to distributing naloxone. It was simple to keep a record of how many people were trained and how many came back saying that they used their naloxone. Looking back, she believes that if they had not kept these basic statistics, it would have been harder to convince authorities to adopt the project.
Bad press: The start of a conversation
The media reported on growing drug use trends and contributed to pervasive stigma against drug users, with headlines like “Common disgrace: Druggies ply trade in premier parks.” One newspaper even ran a series of photographs of two men getting high in a public park and one overdosing and dying and the other one getting arrested. Like many other places in the world, the general public viewed drug users more as a public nuisance than as community members deserving of healthcare.
Despite this negative attitude, naloxone advocates decided to use the media attention to their advantage. In 2005, staff of a local organization wrote a letter to Boston’s mayor in response to the negative media. Informed by naloxone programs in other U.S. cities and the underground work in Boston and the surrounding area, they offered strategies to prevent overdose deaths. The Mayor responded by calling a meeting with the department of public health, and local harm reduction organizations were also invited. By 2006, the Boston health authorities approved a pilot program to train active drug users how to recognize and respond to a drug overdose, and to equip them with naloxone. The City of Boston named program staff “special employees” for whom the city assumed legal liability for activities related to the overdose prevention pilot, which was operated out of the needle exchange program. Soon, a neighboring city started a similar program. Six months later, the results of the pilot were presented and the health authorities made it official.
Collaboration and political support
Eliza recalls that there was initially some concern amongst activists that a city- or state-administered program would not meet the needs of drug users in the same way that underground distribution had. However, she says, “activists working within the city health department ensured that our voices were heard, and when the programs on the city and state level were developed, they really included all of us in the process and valued our input. I’d say that it was a successful collaboration between people on the ground who fought for the right to give out naloxone, and the public health people who could make it happen [on a wider scale] with money and authority.”
The state of Massachusetts (of which Boston is the capital) has now adopted the program, with naloxone pilots in communities throughout the state. A training organization also works with substance abuse treatment programs to provide overdose education and naloxone distribution services. Together these agencies have trained more than 12,000 drug users, their friends and families, service providers, and first responders such as police and firefighters in certain towns about how to prevent and manage overdoses. More than 1,500 reversals have been recorded since the program officially began six years ago. A recent study documented the effectiveness of this approach: Massachusetts communities with overdose education and naloxone distributions programs had lower overdose death rates than similar communities without the programs.