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RRP 13-446 – HSR&D Study

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RRP 13-446
Implementing Overdose Education and Naloxone Distribution: A Formative Evaluation
Elizabeth Marie Oliva PhD
VA Palo Alto Health Care System, Palo Alto, CA
Palo Alto, CA
Funding Period: July 2014 - June 2015

BACKGROUND/RATIONALE:
The number of patients treated by the VA who have opioid use disorders is increasing dramatically. Residential treatment may be one treatment option for these patients; however, there may be an iatrogenic effect of residential treatment on patients' risk for opioid overdose (likely related to loss of tolerance) with an almost 16-fold increase in excess mortality risk in the 4-weeks immediately following residential treatment discharge (Ravndal & Amudsen, 2010). Opioid Overdose Education and Naloxone Distribution (OEND) is a cost-effective intervention associated with reduced opioid overdose mortality that trains individuals to prevent, recognize and respond to an opioid overdose (including training on how to respond with naloxone, a medication used to reverse opioid overdose). Although OEND has the potential to reduce opioid-related mortality if successfully implemented within VA, VISNs in the pre-implementation stage have already come across significant barriers to implementation. Given that OEND is a low-cost, low-intensity and cost-effective intervention that can save lives, it is imperative that the VA identify strategies to facilitate and speed adoption of this life-saving intervention and to disseminate these strategies to the field in a way that will promote adoption. VA leadership has encouraged OEND implementation and various VA offices have been working together to facilitate OEND implementation.

OBJECTIVE(S):
The proposed study will formatively evaluate OEND implementation among initial adopters of OEND within the VA-i.e., VISNs 10 and 21-with the following specific objectives: (1) to identify important barriers and facilitators of OEND implementation and evaluate the effectiveness of different implementation strategies, and (2) to use the information gained from Aim 1 to inform a national, SharePoint-based toolkit for OEND implementation.

METHODS:
Stetler et al.'s (2011) guide for applying a revised version of the Promoting Action on Research Implementation in Health Services (PARIHS) framework for implementation will guide our formative evaluation of OEND implementation. For our first objective, focused interviews will be conducted with approximately 40 key stakeholders-e.g., clinicians, pharmacy, general counsel, mental health leadership-and focus groups will be conducted with 3-4 groups of 4-6 patients each. Qualitative analyses of these interviews and focus groups will inform the development of a guidebook that will identify effective strategies for OEND implementation and key barriers/facilitators. This guidebook will be used to address the second objective in that it will be used to inform the national, SharePoint-based toolkit.

FINDINGS/RESULTS:
We have a paper describing findings from our focus group--Oliva, E.M., Nevedal, A., Lewis, E.T., McCaa, M.D., Cochran, M.F., Konicki, P.E., Davis, C.S., & Wilder, C.
(2016). Patient perspectives on an opioid overdose education and naloxone distribution program in the US Department of Veterans Affairs. Substance Abuse, 37(1): 118-26. Below is the abstract from that paper:

BACKGROUND:
In an effort to prevent opioid overdose mortality among Veterans, Department of Veterans Affairs (VA) facilities began implementing opioid overdose education and naloxone distribution (OEND) in 2013 and a national program began in 2014. VA is the first national health care system to implement OEND. The goal of this study is to examine patient perceptions of OEND training and naloxone kits.

METHODS:
Four focus groups were conducted between December 2014 and February 2015 with 21 patients trained in OEND. Participants were recruited from a VA residential facility in California with a substance use disorder treatment program (mandatory OEND training) and a homeless program (optional OEND training). Data were analyzed using matrices and open and closed coding approaches to identify participants' perspectives on OEND training including benefits, concerns, differing opinions, and suggestions for improvement.

RESULTS:
Veterans thought OEND training was interesting, novel, and empowering, and that naloxone kits will save lives. Some veterans expressed concern about using syringes in the kits. A few patients who never used opioids were not interested in receiving kits. Veterans had differing opinions about legal and liability issues, whether naloxone kits might contribute to relapse, and whether and how to involve family in training. Some veterans expressed uncertainty about the effects of naloxone. Suggested improvements included active learning approaches, enhanced training materials, and increased advertisement.

CONCLUSIONS:
OEND training was generally well received among study participants, including those with no indication for a naloxone kit. Patients described a need for OEND and believed it could save lives. Patient feedback on OEND training benefits, concerns, opinions, and suggestions provides important insights to inform future OEND training programs both within VA and in other health care settings. Training is critical to maximizing the potential for OEND to save lives, and this study includes specific suggestions for improving the effectiveness and acceptability of training.


We also presented on preliminary results from the key stakeholder interviews at the HSR&D Conference last year. Here are the findings we presented:

This poster reports on the preliminary analysis of our key stakeholder interview data.
Facilitators of OEND implementation:
--Positive clinical perceptions regarding the need/benefit of OEND
--Leadership and pharmacy support
--Technical assistance with implementation (e.g., resources)
--Motivated stakeholders

Barriers to OEND implementation:
--Competing clinical demands; not having time
--Lack of leadership and pharmacy support

Issues raised regarding OEND
--Concerns about potential iatrogenic effects may be slowing uptake
--Need to reach more at-risk Veterans and need for demo kits
--Expansion into primary care/pain management: "I think [expanding] is excellent. [.] statistically, it's people that are using the opioid pain medications that are overdosing and dying the most. So, definitely, I think it would be important to implement in both of those places. Now how well-received that would be, I think there needs to be some education done to bring people on board."
--OEND as a way to keep non-treatment seeking patients connected to program: ".we've tried very, very hard to get him [a Veteran] back into treatment and back into PTSD treatment. He's not been open to that. But that day he came through, he admitted that he was shooting heroin. So, we offered him OEND. He was willing to do that."

Innovative OEND implementation strategies
--Offer OEND through referral/consult and VTEL; hands-on training using Family and Friends CPR kit obtained through nursing services; include OEND to patients being screened/evaluated for services; include all staff being trained as a program-specific CARF competency; pre- and post-test training assessment

IMPACT:
This study provided crucial information for VA OEND implementation and has informed improvements of the VA National OEND SharePoint. The SharePoint had over 5,800 visitors this past year and provides tools and resources for providers seeking to implement OEND. The tools and resources have likely contributed to the dispensing of over 21,000 naloxone kits and the 172 reported opioid overdose reversals since the beginning of the VA national OEND program in May 2014. The preliminary findings from the RRP were informative to the national OEND program as we were collecting data from the sites during initial deployment of the national program. Throughout the course of this research project, we rapidly integrated suggestions for improvement given that the PI is the VA National OEND Coordinator. For instance, one interviewee said that the VA OEND SharePoint site had a lot of great information but it was not easily navigable and might be overwhelming for providers who do not have a lot of time to peruse the site. We revised the homepage to make it a one-stop shop for information (e.g., hyperlinks to national tools, YouTube "How To" videos, etc.).

PUBLICATIONS:

Journal Articles

  1. Oliva EM, Nevedal A, Lewis ET, McCaa MD, Cochran MF, Konicki PE, Davis CS, Wilder C. Patient perspectives on an opioid overdose education and naloxone distribution program in the U.S. Department of Veterans Affairs. Substance Abuse. 2016 Jan 1; 37(1):118-26.
  2. Finlay AK, Oliva EM, Timko C, Moos RH, Cronkite R. Predictors of 30-year mortality in depressed and comparison samples. Journal of affective disorders. 2014 Aug 1; 165:114-9.
  3. Oliva EM, Midboe AM, Lewis ET, Henderson PT, Dalton AL, Im JJ, Seal K, Paik MC, Trafton JA. Sex differences in chronic pain management practices for patients receiving opioids from the Veterans Health Administration. Pain medicine (Malden, Mass.). 2015 Jan 1; 16(1):112-8.
  4. Oliva EM, Bowe T, Harris AH, Trafton JA. Datapoints: false starts in psychotherapy for substance use disorders and PTSD in the VHA. Psychiatric services (Washington, D.C.). 2013 Aug 1; 64(8):722.
Journal Other

  1. Oliva EM, Harris AH. If pharmacotherapies for alcohol use disorders are effective, why are they underutilised? Evidence-based medicine. 2014 Dec 1; 19(6):230-1.
Center Products

  1. Oliva EM. Saving Veterans Lives through Implementation of Opioid Overdose Education and Naloxone Distribution (OEND). Presented at a Public Hearing on Exploring Naloxone Uptake and Use. Federal Drug Administration Center for Drug Evaluation and Research; 2015 Jul 1; Silver Spring, MD. 2015 Jul 1.
  2. Oliva EM, Burgard J, Drexler K. Overdose Education and Naloxone Distribution (OEND) to Prevent Opioid Overdose. Oral presentation (telephone conference) to the VISN 23 Substance Use Disorder (SUD) Leads. 2014 May 2.
VA Cyberseminars

  1. Gordon AJ, Oliva EM, Wells DL, Harding JD. Opioid overdose education and naloxone distribution to prevent opioid overdose mortality [Buprenorphine Initiative in the VA Monthly Webinar Series]. [Cyberseminar]. 2015 Sep 8.
  2. Oliva EM, Wells D, Stock C. Naloxone Kit Updates: "Recommendations for Issuing Naloxone Kits and Naloxone Autoinjectors for the VA Overdose Education and Naloxone Distribution (OEND) Program." Presentation as part of the VA Pharmacy Benefits Management (PBM) Webinar Series. [Cyberseminar]. 2015 Jul 21.
  3. Oliva EM, Goodman F, Christopher M. Naloxone Kit Updates: Recommendations for Issuing Naloxone Kits and Naloxone Autoinjectors for the VA Overdose Education and Naloxone Distribution (OEND) Program. VA Pharmacy Benefits Management (PBM) Webinar Series. [Cyberseminar]. 2015 Apr 21.
  4. Oliva EM, Goodman F, Sproul R. Update -- Naloxone Kit: What, For Whom, and How? VA Pharmacy Benefits Management (PBM) Webinar Series. [Cyberseminar]. 2014 Dec 16.
  5. Oliva EM, Goodman F, Sproul R. Naloxone Kit: What, For Whom, and How? Presentation as part of the VA Pharmacy Benefits Management (PBM) Webinar Series. [Cyberseminar]. 2014 Oct 20.
  6. Oliva EM. Spotlight on Pain Management - Opioid Overdose Education and Naloxone Distribution (OEND): Preventing and Responding to an Opioid Overdose. [Cyberseminar]. 2014 Sep 2.
  7. Oliva EM, Konicki PE. Opioid Risk Mitigation and the Role of Naloxone Rescue. Oral presentation (Adobe Connect webinar) to VA SCAN-ECHO (Specialty Care Access Network-Extension for Community Healthcare Outcomes). [Cyberseminar]. 2014 May 27.
  8. Oliva EM, Konicki PE, Cochran M. Overdose Education and Naloxone Distribution (OEND): A Brief Overview. Oral presentation (LYNC Webinar) as part of the Mental Health Residential Rehabilitation Treatment Programs (MH RRTP) Continuing Education Series. [Cyberseminar]. 2014 Feb 20.
Conference Presentations

  1. Mudumbai S, Unger-Hu K, Oliva EM, Lewis ET, Trafton JA, Mariano ER, Stafford RS, Wagner TH, Clark D. Time to Cessation of Postoperative Opioids: A National-level, Cross-sectional Analysis of the Veterans Affairs Healthcare System. Paper presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 8; Philadelphia, PA.
  2. Oliva EM, McCaa MD, Lewis ET, Cochran MF, Konicki PE, Wilder CM. Formative Evaluation of Life-Saving Opioid Overdose Education and Naloxone Distribution (OEND) in VISNs 10 and 21. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 8; Philadelphia, PA.
  3. Oliva EM. Implementing Opioid Overdose Education and Naloxone Distribution (OEND) to Prevent Opioid Overdose Mortality. Presented at: VA / Department of Defense Suicide Prevention Annual Conference; 2015 Jan 28; Dallas, TX.
  4. Oliva EM. Opioid Interventions: Naloxone and Other Option. Teleconference. Presented at: VA VISN 23 Substance Use Disorders Programs Conference; 2014 Sep 11; Menlo Park, CA.
  5. Harris AH, Bowe T, Del Re AC, Finlay AK, Oliva EM, Rubinsky AD. Quasi-Experimental Effects of Extended Release Naltrexone in US Veteran Health Administration Patients with Alcohol Dependence. Poster session presented at: Research Society on Alcoholism Annual Scientific Meeting; 2014 Jun 22; Bellevue, WA.


DRA: Substance Abuse and Addiction
DRE: Treatment - Comparative Effectiveness
Keywords: QUERI Implementation
MeSH Terms: none