"Wanna cry this out real quick?": an examination of secondary traumatic stress risk and resilience among post-overdose outreach staff in Massachusetts.

BACKGROUND: Post-overdose outreach programs engage overdose survivors and their families soon after an overdose event. Staff implementing these programs are routinely exposed to others' trauma, which makes them vulnerable to secondary traumatic stress (STS) and compassion fatigue. The purpose of this study was to explore experiences of STS and associated upstream and downstream risk and protective factors among program staff. METHODS: We conducted a post-hoc analysis of semi-structured interviews with post-overdose outreach program staff in Massachusetts. Transcripts were analyzed using a multi-step hybrid inductive-deductive approach to explore approaches and responses to outreach work, factors that might give rise to STS, and compassion fatigue resilience. Findings were organized according to the three main constructs within Ludick and Figley's compassion fatigue resilience model (empathy, secondary traumatic stress, and compassion fatigue resilience). RESULTS: Thirty-eight interviews were conducted with staff from 11 post-overdose outreach programs in Massachusetts. Within the empathy construct, concern for others' well-being emerged as a motivator to engage in post-overdose outreach work - with staff trying to understand others' perspectives and using this connection to deliver respectful and compassionate services. Within the secondary traumatic stress construct, interviewees described regular and repeated exposure to others' trauma - made more difficult when exposures overlapped with staff members' personal social spheres. Within the compassion fatigue resilience construct, interviewees described the presence and absence of self-care practices and routines, social supports, and workplace supports. Job satisfaction and emotional detachment from work experiences also arose as potential protective factors. Interviewees reported inconsistent presence and utilization of formal support for STS and compassion fatigue within their post-overdose outreach teams. CONCLUSION: Post-overdose outreach program staff may experience secondary traumatic stress and may develop compassion fatigue, particularly in the absence of resilience and coping strategies and support. Compassion fatigue resilience approaches for post-overdose outreach staff warrant further development and study.

Privacy and confidentiality in Massachusetts' post-overdose outreach programs: Mixed methods analysis of outreach staff surveys and interviews.

BACKGROUND: Public health-public safety partnerships for post-overdose outreach have emerged in many communities to prevent future overdose events. These efforts often identify overdose survivors through emergency call data and seek to link them with relevant services. The aim of this study was to describe how post-overdose outreach programs in Massachusetts manage the confidentiality of identifiable information and privacy of survivors. METHODS: In 2019, 138 Massachusetts programs completed surveys eliciting responses to questions about program operations. Descriptive statistics were calculated from the closed-ended survey responses. Thirty-eight interviews were conducted among outreach staff members during 2019-2020. Interview transcripts and open-ended survey responses were thematically analyzed using deductive and inductive approaches. RESULTS: Of programs that completed the survey, 90 % (n = 124/138) reported acting to protect the privacy of survivors following overdose events, and 84 % (n = 114/135) reported implementing a protocol to maintain the confidentiality of personal information. Interviews with outreach team members indicated substantial variation in practice. Outreach programs regularly employed discretion in determining actions in the field, sometimes undermining survivor privacy and confidentiality (e.g., by disclosing the overdose event to family members). Programs aiming to prioritize privacy and confidentiality attempted to make initial contact with survivors by phone, limited or concealed materials left behind when no one was home, and/or limited the number of contact attempts. CONCLUSIONS: Despite the establishment of privacy and confidentiality protocols within most post-overdose outreach programs, application of these procedures was varied, discretionary, and at times viewed by staff as competing with engagement efforts. Individual outreach overdose teams should prioritize privacy and confidentiality during outreach to protect overdose survivors from undesired exposure. In addition to individual program changes, access to overdose survivor information could be changed across all programs to bolster privacy and confidentiality protocols. For example, transitioning the management of overdose-related information to non-law enforcement agencies would limit officers' ability to disseminate such information at their discretion.

Characteristics of post-overdose outreach programs and municipal-level opioid overdose in Massachusetts.

BACKGROUND: Post-overdose outreach programs have proliferated in response to opioid overdose. Implementing these programs is associated with reductions in overdose rates, but the role of specific program characteristics in overdose trends has not been evaluated. METHODS: Among 58 Massachusetts municipalities with post-overdose outreach programs, we examined associations between five domains of post-overdose outreach program characteristics (outreach contact rate, naloxone distribution, coercive practices, harm reduction activities, and social service provision or referral) and rates of fatal opioid overdoses and opioid-related emergency medical system responses (i.e., ambulance activations) per calendar quarter from 2013 to 2019 using segmented regression analyses with adjustment for municipal covariates and fixed effects. For both outcomes, each domain was modeled: a) individually, b) with other characteristics, and c) with other characteristics and municipal-level fixed effects. RESULTS: There were no significant associations (p < 0.05) between outreach contact rate, naloxone distribution, coercive practices, or harm reduction activities with municipal fatal overdose trends. Municipalities with programs providing or referring to more social services experienced 21% fewer fatal overdoses compared to programs providing or referring to more social services (Rate Ratio (RR) 0.79, 95% Confidence Interval (CI) 0.66-0.93, p = 0.01). Compared to municipalities in quarters when programs had no outreach contacts, municipalities with some, but less than the median outreach contacts, experienced 14% lower opioid-related emergency responses (RR 0.86, 95% CI 0.78-0.96, p = 0.01). Associations between naloxone distribution, coercive practices, harm reduction practices, or social services and opioid-related emergency responses were not consistently significant across modeling approaches. CONCLUSION: Municipalities with post-overdose outreach programs providing or referring to more social services had lower fatal opioid overdose rates. Municipalities in quarters when programs outreached to overdose survivors had fewer opioid-related emergency responses, but only among programs with below the median number of outreach contacts. Social service linkage should be core to post-overdose programs. Evaluations should assess program characteristics to optimize program design.

The police paradox: A qualitative study of post-overdose outreach program implementation through public health-public safety partnerships in Massachusetts.

BACKGROUND: Post-overdose outreach has emerged in the United States as an increasingly common response to non-fatal overdose. This qualitative study investigates the implementation of such programs through public health-public safety partnerships in Massachusetts. METHODS: We conducted semi-structured interviews with post-overdose outreach team members, overdose survivors, and family members who received outreach. Interview transcripts were inductively analyzed to identify emergent themes and subsequently organized within the framework of Ecological Systems Theory. RESULTS: Forty-nine interviews were conducted, including 15 police officers (80% male, 100% non-Hispanic White); 23 public health partners (48% male, 87% non-Hispanic White); 8 overdose survivors who received outreach services and 3 parents of survivors who received services (collectively 27% male, 64% non-Hispanic White). Implementation factors identified across all levels (macrosystem, exosystem, mesosystem, and microsystem) of Ecological Systems Theory included key program facilitators, such as access to police data and funding (macro), interagency collaboration (exo), shared recognition of community needs (exo), supportive relationships among team members (meso), and program champions (micro). Common barriers included inherent contradictions between policing and public health mandates (macro), poor local treatment and service capacity (exo), divergent staff views of program goals (exo), overdose survivors' prior negative experiences with law enforcement (meso), difficulty locating overdose survivors (meso), and police officers' lack of qualifications or training in providing psycho-social services (micro). CONCLUSIONS: Most post-overdose outreach programs in this study were dependent on funding and data-sharing partnerships, which police agencies largely controlled. Yet, police participation, especially during outreach visits presented numerous challenges for engaging overdose survivors and establishing non-coercive linkages with evidence-based services, which may undermine the public health goals of these programs. These findings should inform state and federal efforts to expand the role of law enforcement in behavioral health initiatives.

Association of Implementation of Postoverdose Outreach Programs With Subsequent Opioid Overdose Deaths Among Massachusetts Municipalities.

Importance: Nonfatal opioid overdose is the leading risk factor for subsequent fatal overdose and represents a critical opportunity to reduce future overdose and mortality. Postoverdose outreach programs emerged in Massachusetts beginning in 2013 with the main purpose of linking opioid overdose survivors to addiction treatment and harm reduction services. Objective: To evaluate whether the implementation of postoverdose outreach programs among Massachusetts municipalities was associated with lower opioid fatality rates compared with municipalities without postoverdose outreach programs. Design, Setting, and Participants: This retrospective interrupted time-series analysis was performed over 26 quarters (from January 1, 2013, through June 30, 2019) across 93 municipalities in Massachusetts. These 93 municipalities were selected based on a threshold of 30 or more opioid-related emergency medical services (EMS) responses in 2015. Data were analyzed from November 2021 to August 2022. Exposures: The main exposure was municipality postoverdose outreach programs. Municipalities had various program inceptions during the study period. Main Outcomes and Measures: The primary outcome was quarterly municipal opioid fatality rate per 100 000 population. The secondary outcome was quarterly municipal opioid-related EMS response (ambulance trips) rates per 100 000 population. Results: The mean (SD) population size across 93 municipalities was 47 622 (70 307), the mean (SD) proportion of female individuals was 51.5% (1.5%) and male individuals was 48.5% (1.5%), and the mean (SD) age proportions were 29.7% (4.0%) younger than 25 years, 26.0% (4.8%) aged 25 to 44 years, 14.8% (2.1%) aged 45 to 54 years, 13.4% (2.1%) aged 55 to 64 years, and 16.1% (4.4%) aged 65 years or older. Postoverdose programs were implemented in 58 municipalities (62%). Following implementation, there were no significant level changes in opioid fatality rate (adjusted rate ratio [aRR], 1.07; 95% CI, 0.96-1.19; P = .20). However, there was a significant slope decrease in opioid fatality rate (annualized aRR, 0.94; 95% CI, 0.90-0.98; P = .003) compared with the municipalities without the outreach programs. Similarly, there was a significant slope decrease in opioid-related EMS response rates (annualized aRR, 0.93; 95% CI, 0.89-0.98; P = .007). Several sensitivity analyses yielded similar findings. Conclusions and Relevance: In this study, among Massachusetts municipalities with high numbers of opioid-related EMS responses, implementation of postoverdose outreach programs was significantly associated with lower opioid fatality rates over time compared with municipalities that did not implement such programs. Program components, including cross-sectoral partnerships, operational best practices, involvement of law enforcement, and related program costs, warrant further evaluation to enhance effectiveness.

The Massachusetts Department of Public Health Post Overdose Support Team Initiative: A Public Health-Centered Co-Response Model for Post-Overdose Outreach.

CONTEXT: Post-overdose outreach programs have emerged in response to surging overdose deaths amid fentanyl contamination of the illicit opioid supply. Predominantly centered in police departments in collaboration with public health providers, these programs conduct home-based outreach with survivors and their social networks following an overdose. APPROACH: We describe implementation of the Post Overdose Support Team (POST) initiative, an ongoing public health funded and centered approach. Post Overdose Support Team is a person-centered model led by harm reductionists in health and human services agencies in collaboration with municipal first responders. The goal of POST is to engage overdose survivors and their social network to improve general health, connect people to services (including access to treatment, if desired), and reduce risk of subsequent overdose. IMPLEMENTATION: Nine agencies in Massachusetts that are part of the state's overdose education and naloxone distribution network implemented POST programs, covering 28 municipalities. The POST teams conduct home-based outreach with individuals who experienced an opioid-related overdose to provide a menu of services, including naloxone rescue kits, overdose response and risk reduction planning, referral to treatment for substance use disorders, including medication for opioid use disorder, and referral to recovery and family supports. EVALUATION: From October 2017 to October 2021, the POST teams attempted to reach 5634 overdose survivors via 10 536 outreach visits. Teams successfully engaged 3014 survivors, either directly or through contact with their social network (53.5% success rate). Using data from a real-time encounter-level database, monthly peer-sharing calls with program sites, and annual site visits, we describe the implementation of the POST initiative and provide practice-based recommendations and lessons learned. DISCUSSION: Early evidence suggests that the POST initiative is meeting its goal to engage overdose survivors, improve general health, and reduce subsequent overdose risk. Future evaluations should examine long-term outcomes among participants, including service linkages and incremental behavior change.

Warrant checking practices by post-overdose outreach programs in Massachusetts: A mixed-methods study.

BACKGROUND: Post-overdose outreach programs engage survivors in harm reduction and treatment to prevent future overdoses. In Massachusetts, these emerging programs commonly deploy teams comprised of police and public health professionals based on 911 call information. Some teams use name/address data to conduct arrest warrant checks prior to outreach visits. We used mixed methods to understand approaches to outreach related to warrant checking, from the perspectives of police and public health outreach agencies and staff. METHODS: We analyzed a 2019 statewide survey of post-overdose outreach programs in Massachusetts to classify approaches to warrant checking and identify program and community factors associated with particular approaches. Ethnographic analysis of qualitative interviews conducted with outreach staff helped further contextualize outreach program practices related to warrants. RESULTS: A majority (57% - 79/138) of post-overdose outreach programs in Massachusetts conducted warrant checks prior to outreach. Among programs that checked warrants, we formulated a taxonomy of approaches to handling warrants: 1) performing outreach without addressing warrants (19.6% - 27/138), 2) delaying outreach until warrants are cleared (15.9% - 22/138), 3) arresting the survivor (11/138 - 8.0%), 4) taking a situational approach (10/138 - 7.2%), 5) not performing outreach (9/138 - 6.5%). Program characteristics and staff training did not vary across approaches. From police and public health outreach staff interviews (n = 38), we elicited four major themes: a) diverse motivations precede warrant checking, b) police officers feel tension between dual roles, c) warrants alter approaches to outreach, and d) teams leverage warrants in relationships. Findings from both analyses converged to demonstrate unintended consequences of warrant checking. CONCLUSION: Checking warrants prior to post-overdose outreach visits can result in arrest, delayed outreach, and barriers to obtaining services for overdose survivors, which can undermine the goal of these programs to engage overdose survivors. With the public health imperative of engaging overdose survivors, programs should consider limiting warrant checking and police participation in field activities.

Characteristics of post-overdose public health-public safety outreach in Massachusetts.

BACKGROUND: As a response to mounting overdose fatalities, cross-agency outreach efforts have emerged to reduce future risk among overdose survivors. We aimed to characterize such programs in Massachusetts, with focus on team composition, approach, services provided, and funding. METHODS: We conducted a two-phase cross-sectional survey of public health and safety providers in Massachusetts. Providers in all 351 municipalities received a screening survey. Those with programs received a second, detailed survey. We analyzed responses using descriptive statistics. RESULTS: As of July 2019, 44 % (156/351) of Massachusetts municipalities reported post-overdose outreach programs, with 75 % (104/138) formed between 2016-2019. Teams conducted home-based outreach 1-3 days following overdose events. Police departments typically supplied location information on overdose events (99 %, 136/138) and commonly participated in outreach visits (86 %, 118/138) alongside public health personnel, usually from community-based organizations. Teams provided or made referrals to services including inpatient addiction treatment, recovery support, outpatient medication, overdose prevention education, and naloxone. Some programs deployed law enforcement tools, including pre-visit warrant queries (57 %, 79/138), which occasionally led to arrest (11 %, 9/79). Many programs (81 %, 112/138) assisted families with involuntary commitment to treatment - although this was usually considered an option of last resort. Most programs were grant-funded (76 %, 104/136) and engaged in cross-municipal collaboration (94 %, 130/138). CONCLUSIONS: Post-overdose outreach programs have expanded, typically as collaborations between police and public health. Further research is needed to better understand the implications of involving police and to determine best practices for increasing engagement in treatment and harm reduction services and reduce subsequent overdose.

Predictive utility of an emergency department decision support tool in patients with active suicidal ideation.

Emergency department (ED) clinicians routinely decide the disposition of patients with suicidal ideation, with potential consequences for patient safety, liability, and system costs and resources. An expert consensus panel recently created a 6-item decision support tool for patients with passive or active suicidal ideation. Individuals scoring a 0 (exhibiting none of the tool's 6 items) are considered "lower risk" and suitable for discharge, while those with non-0 scores are considered "elevated risk" and should receive further evaluation. The current study tested the predictive utility of this tool using existing data from the Emergency Department Safety Assessment and Follow-up Evaluation. ED patients with active suicide ideation (n = 1368) were followed for 12 months after an index visit using telephone assessment and medical chart review. About 1 in 5 patients had attempted suicide during follow-up. Because of the frequency of serious warning signs and risk factors in this population, only three patients met tool criteria for "lower risk" at baseline. The tool had perfect sensitivity, but exceptionally low specificity, in predicting suicidal behavior within 6 weeks and 12 months. In logistic regression analyses, several tool items were significantly associated with suicidal behavior within 6 weeks (suicide plan, past attempt) and 12 months (suicide plan, past attempt, suicide intent, significant mental health condition, irritability/agitation/aggression). Although the tool did not perform well as a binary instrument among those with active suicidal ideation, having a suicide plan identified almost all attempters while suicide plan and past attempt identified over four-fifths of near-term attempts. (PsycINFO Database Record

Post opioid overdose outreach by public health and public safety agencies: Exploration of emerging programs in Massachusetts.

BACKGROUND: Opioid overdose is a significant public health problem. Collaborative programs between local public health and public safety agencies have emerged to connect overdose survivors and their personal networks with harm reduction and addiction treatment services following a non-fatal overdose event. This study explored the prevalence of these programs in Massachusetts and the different ways they have been structured and function. METHODS: We sent an online screening questionnaire to police and fire departments in all 351 communities in Massachusetts to find instances in which they collaborated with a community-based public health agency to implement a post-overdose outreach and support program. We conducted telephone interviews with communities that implemented this type of program and categorized programs based on their structure, outreach approach, and other key characteristics. RESULTS: Police and fire personnel from 110 of the 351 communities in Massachusetts (31% response rate) completed the screening survey. Among respondents, 21% (23/110) had implemented a collaborative, community-based, post-overdose program with a well-defined process to connect overdose survivors and their personal networks with support services or addiction treatment services. Using data from the interviews, we identified four types of programs: (1) Multi-Disciplinary Team Visit, (2) Police Visit with Referrals, (3) Clinician Outreach, and (4) Location-Based Outreach. CONCLUSIONS: This study represents the first attempt to systematically document an emerging approach intended to connect opioid overdose survivors and their personal networks with harm reduction and addiction treatment services soon after a non-fatal overdose event. These programs have the potential to increase engagement with the social service and addiction treatment systems by those who are at elevated risk for experiencing a fatal opioid overdose.

Can an Infusion of Federal Funds Result in Sustainable Projects? An Evaluation of Suicide Prevention Programs.

Our study evaluated the sustainability of programs in early cohorts of the Garrett Lee Smith (GLS) Memorial Act suicide prevention initiative, a major source of federal funding for youth suicide prevention among states, tribes, and institutions of higher education. We sought to: (1) determine whether suicide prevention activities initiated with federal support continued after funding ended, and (2) identify factors associated with sustainment. Thirty-three sites between 1 and 4 years beyond the end of their GLS grant participated in a retrospective online survey assessing their level of suicide prevention activity 1 year before, during (during-GLS), and 1 year after funding (after-GLS). We found that, on average, sites experienced a 6% decrease in their overall level of activity from during- to after-GLS. Twenty-two (67% of responding sites) exhibited either an increase in activity level or no more than a 10% decline from during- to after-GLS periods. After-GLS scores for the 11 remaining sites declined between 11 and 30% from their during-GLS levels. We conducted semi-structured follow-up interviews with 13 sites that successfully continued their activities to explore factors associated with sustainability. Our findings indicate that program actions in the during-GLS period associated with sustainability included: maintaining a sustainability mindset, developing and nurturing partnerships and relationships, embedding services in parent organizations, pursuing new and diversified funding, and implementing cost-reduction efficiencies. Actions in the after-GLS period associated with sustainability included: obtaining funding from other sources, reconfiguring, and maintaining continuous leadership.

Evaluation of criteria for developing traffic safety materials for Latinos.

This quantitative study assessed the validity of guidelines that identified four key characteristics of culturally appropriate Spanish-language traffic safety materials: language, translation, formative evaluation, and credible source material. From a sample of 190, the authors randomly selected 12 Spanish-language educational materials for analysis by 15 experts. Hypotheses included that the experts would rate materials with more of the key characteristics as more effective (likely to affect behavioral change) and rate materials originally developed in Spanish and those that utilized formative evaluation (e.g., pilot tests, focus groups) as more culturally appropriate. Although results revealed a weak association between the number of key characteristics in a material and the rating of its effectiveness, reviewers rated materials originally created in Spanish and those utilizing formative evaluation as significantly more culturally appropriate. The findings and methodology demonstrated important implications for developers and evaluators of any health-related materials for Spanish speakers and other population groups.