LEXINGTON, Ky. (May 14, 2020) – Since the $87 million HEALing Communities Study was announced just over a year ago, the University of Kentucky and its community and state partners have been working diligently to lay the groundwork to get the project up and running.
The ambitious study is organized into six phases, beginning with the basic preparations and leading into actual implementation and monitoring of various evidence-based strategies to reduce opioid deaths. The project is broken down into two waves of eight counties each, with each wave starting at different times. Project activities for the first wave of eight counties – Boyd, Boyle, Clark, Fayette, Floyd, Franklin, Kenton and Madison, collectively known as WAVE 1 – is well underway.
“The way this study is designed, we go through this phased process where we’re working with each of our WAVE 1 communities through their community coalition,” said Sharon Walsh, Ph.D., director of UK’s Center on Drug and Alcohol Research and principal investigator on UK’s HEAL grant. “We step them through the data that we have on their communities, get their feedback, and revise. Then we discuss all the evidence-based practices that are available for selection and we work through that to develop their own community action plan.”
The HEALing Communities Study timeline had been carefully set and was progressing as planned.
And then, COVID-19 rapidly spread across the country. With many of Kentucky’s health care workers focusing their efforts on preparing for the virus, and other industries quickly moving to a work-from-home model, the HEAL team at first wasn’t sure if their community partners had the bandwidth to maintain the timeline of work on the grant.
But when Kentucky Gov. Andy Beshear announced the release of non-violent medically vulnerable inmates and those with Class C or D felonies nearing the end of their sentences in an effort to reduce the spread of COVID-19 in the correctional institutions, the team saw an urgent need to push the study forward by offering one initiative to communities ahead of schedule: the distribution of naloxone to individuals at highest risk for overdose, particularly those being released from local jails.
Each community involved in the project will develop an action plan that involves picking which strategies they are able and willing to initiate in their area. Naloxone distribution in the criminal justice setting was an evidence-based practice that was always “on the menu,” as UK College of Public Health associate professor April Young, Ph.D., describes it, but had been in the plans to begin later this year.
In mid-March during a national call, Walsh pitched the idea of fast-tracking overdose education and naloxone in light of COVID-19 and the national consortium agreed to develop a committee to take up the issue. Young led HEAL’s community engagement and continuum of care teams in Kentucky, Massachusetts, New York and Ohio to get approval to fast-track the initiative.
“The Kentucky team has always operated with a sense of urgency because we are mindful that lives are at stake,” Young said. “We’ve always worked to help our eager communities move as quickly as possible through the process outlined in the study protocol, but when COVID-19 hit, the goalpost moved. It was clear that the standard protocol wasn’t going to cut it if we were going to help those at highest need.”
“We really felt like it was a moral mandate,” Walsh said.
The team immediately began writing a plan, and Young says that within five hours of that call, they had completed a draft protocol. For the next week, researchers from the four states weighed in through a series of revised drafts and meetings before agreement was reached and the plan was approved.
The risk of overdose is increased when people are released from a correctional facility – because they have gone for an extended length of time without using an opioid, their tolerance for the drug has decreased significantly. An attempt to use the same amount of opioid may lead to overdose or death. Naloxone is an opioid antagonist, which means it blocks the effects of opioids and immediately reverses an overdose.
“[The inmates] have been abstinent for some time, and then they’re being released back to the community at a time when everything is upside down,” said Trish Freeman, Ph.D., associate professor in the UK College of Pharmacy. “Their support structures are not necessarily going to be in place, so the risk of overdose is great.”
Once the strategy was approved for implementation, the team presented the option to community coalition members in each of the WAVE 1 counties, all of whom expressed initial interest in providing overdose education and naloxone distribution in their jails.
“I think one of the driving forces for this was that our health care and first responders are already overburdened by COVID-19,” said Carrie Oser, Ph.D., professor in the UK College of Arts & Sciences. “We don’t want to see an increase in overdoses because this could lead to a loss of life, but also we don’t want to further strain those systems, and the jails have been really responsive to this concern.”
Senate Bill 192 (2015) allows healthcare providers to prescribe or dispense naloxone, directly or through a standing order, to any person or agency that is deemed capable of administering the drug in an emergency opioid overdose. Freeman and her colleagues developed a naloxone standing order agreement and Dr. Michelle Lofwall, professor of behavioral science and psychiatry in the UK College of Medicine, signed off on the standing order as the physician of record for all naloxone distributed to the jails.
Education about overdose and how to use the medication is required before the inmate is released – information both they and their family members need to know. Oser and other HEAL colleagues are working with each jail to figure out the best option to push out overdose education, trying to leverage existing resources when possible.
Only two of the jails had overdose education formally implemented as a standard practice for the inmates, but it was only in their substance use treatment units, which serve a limited subset of people. Many of the jails use tablets to provide educational programming and communication to the people who are incarcerated, so providing content digitally has been a priority. In partnership with the jails, Oser and colleagues have implemented overdose education strategies including a video, an interactive educational website training, and scaling up in-person training delivered by jail staff.
The first doses of naloxone were shipped to participating jails just 10 days after the national consortium’s approval of fast-tracking overdose education and naloxone distribution.
“This whole process has been quick,” Oser said. “I would say it was less than seven days between when I first learned about this opportunity and when we actually had our first call with a jail administrator. We developed the jail protocol in less than a week.”
The Fayette County Detention Center (FCDC) is the largest jail in WAVE 1, and last week Lexington’s Urban County Council voted to authorize the receipt and distribution of naloxone in the FCDC. As the community response strategist for Lexington Mayor Linda Gorton and chair of the Fayette County HEALing Communities Study Advisory Committee, Andrea James notes the importance of getting this evidence-based practice in place in Fayette County.
"The mayor and I often speak about the need to deepen the bench as it relates to our efforts to decrease overdose deaths here in Lexington,” James said. “This effort by HCS to fill the huge harm reduction gap created due to COVID-19 is an example of the talent it takes to achieve these life-saving goals for our community. We are thankful to the dedicated and caring staff at our Community Corrections for understanding this need and for stepping up to helping to make this happen."
Amy Baker, program coordinator for Lexington’s Substance Use Disorder Intervention Program, has worked closely with members of UK’s Center on Drug and Alcohol Research for several years and says the group has been an integral part of responding to multiple facets of substance use disorder for Lexington and beyond.
“Although CDAR calls the University of Kentucky home, the advances made in substance use disorder interventions because of the rigorous research and evaluation conducted there are shared throughout the world,” Baker said. “The quick response to remove the barrier the coronavirus caused the naloxone distribution program at the detention center is just one example of the dedication of the team behind implementing the HEAL grant. I am grateful that the federal government recognized the level of expertise of Dr. Walsh and the Kentucky HEAL team and look forward to working alongside them to implement lifesaving strategies.”
So far, three counties are fully onboarded with the naloxone initiative in their jails with two – including Fayette County – to begin distribution next week. However, the criminal justice setting is just one of several opportunities to get the life-saving medication to people who need it. The HEAL team is next working with the communities to get naloxone to other locations for distribution, including treatment facilities and syringe service programs.
“That presents another challenge. Several of our syringe service programs are strained, because they’re run out of the public health departments and people have been redeployed to address COVID-19,” Walsh said. “So we’re identifying gaps. We’re also tracking the impact on COVID-19 on overdoses and other outcomes we think are relevant because we think our target population is particularly vulnerable to the consequences of COVID-19 for a variety of reasons.”
Despite the wrenches the COVID-19 pandemic had thrown in their initial plans, the team says it’s a relief to launch one of the evidence-based practices they hope will save many Kentucky lives in this time of great community need, though they wish the effort could have been launched even earlier to reach even more people. However, they agree that ushering the protocol through approval by four states’ research teams and eight community coalitions then developing a rollout strategy consistent with state policy and jails’ needs in a matter of weeks is a major accomplishment.
“This is a big win for us to be able to execute this so quickly and serve so many people,” Oser said. “And it’s not just benefiting people who are getting out of jail. It’s also helping their family, friends and networks – the people they may be social distancing with at home – who may also be at risk for an opioid overdose. It’s not just serving one person. It’s serving the community.”
“So you’ve had this timeline and thought you were in good shape – and then all of a sudden, it’s like, ‘Oh, we need to do this next week,’” Freeman said. “But this is really one of those situations where you have a great team of faculty and staff working together to make it happen… and that, I think, is what makes this such a beautiful project.”