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Drug treatment can decrease opioid overdose risk by helping individuals stop or reduce their drug use. At the same time, drug treatment lowers a person’s tolerance to opioids which can actually increase risk for overdose. The periods before, during, and after drug treatment can be particularly risky times for overdose.
Talking about overdose
Overdose can be a sensitive topic for both clients and counselors. Clients may not feel the topic is relevant to them. Counselors may feel uncertain how to discuss the realities of overdose risk during relapse while simultaneously building client confidence in recovery. The key to reducing any discomfort is to:
- integrate overdose prevention into multiple areas of the treatment program.
- normalize overdose education for all treatment clients.
The following are good opportunities to discuss overdose with clients:
- Intake assessment
- New client orientation or OTP induction
- Individual counseling
- Group sessions, especially relapse prevention groups
- Review of positive drug screen results
- Discharge planning
- When a client overdoses
- International Overdose Awareness Day (August 31, just before National Recovery Month)
To help normalize conversations about overdose:
- Make overdose a visible topic. Lobby posters, educational brochures, and handouts show that staff care about overdose and want to talk about it.
- Make it a standard practice to discuss overdose with all clients, so no one feels singled out for being more “at-risk” than others. Start conversations with:
- I talk with all of my clients about overdose because the topic is so important right now. And because I want everyone to have the best information.
- Even if you never used opioids or you think you’ll never use opioids again, you probably know someone who still does. You might need to help someone else someday.
- We can feel confident that we’ll stay abstinent, but we’ve all seen relapse happen. And with opioids, the risk of overdose is real. So we want everyone to have this information – to help yourself or maybe someone you care about.
- Emphasize concern for the client’s safety and survival. No slip up or relapse should be fatal.
- Reinforce the client’s ability to help others and the community. You can help spread this information to others or you might even be in a position to safe a life.
- See overdose education as an opportunity to have deeper conversations about behavior change.
Overdose prevention in drug treatment
There are many ways to incorporate overdose prevention into drug treatment. Specifically, treatment providers can:
- Train staff to recognize and respond to overdose incidents on site and to administer naloxone.
- Include overdose risk as part of routine intake assessments.
- Integrate overdose prevention topics into client education curriculum.
- Train staff to discuss overdose risk within relapse prevention counseling.
- Provide clients with naloxone (e.g., through prescription or direct distribution).
For more information on how to integrate overdose prevention into drug treatment:
- Integrating Opioid Overdose Prevention Strategies into Treatment MA Bureau of Substance Abuse Services
- Incorporating overdose prevention, response, and experience into substance use disorder treatment Heartland Health Outreach
The American Society of Addiction Medicine (ASAM) recommends that drug treatment agencies:
- maintain naloxone on-site for overdose emergencies: Public Policy Statement on the Use of Naloxone for the Prevention of Overdose Deaths.
- provide naloxone to clients and their families: National Practice Guideline for the Use of Medications in the Treatment of Addiction Involving Opioid Use
Drug treatment agencies can connect their clients with naloxone in a number of ways:
- Purchase naloxone for staff to distribute directly to clients.
- Have a Medical Director or other prescriber write prescriptions for naloxone that clients can then fill at any pharmacy.
- Partner with a local pharmacy that can directly prescribe naloxone (and in some cases, deliver to your facility). See a list of WA pharmacies here.
- Partner with a community program that can come to your facility to provide client education and distribute naloxone.
For more information or technical assistance on naloxone for drug treatment clients, email the Center for Opioid Safety Education at firstname.lastname@example.org.
Medication-assisted treatment: long-term overdose prevention
While naloxone is a short-term antidote to opioid overdose, stabilizing and treating opioid use disorder with medication-assisted treatment offers long-term protection against overdose. Recent research showed that individuals enrolled in MAT were 50% less likely to die from an overdose than those enrolled only in psychological-based treatment. Pierce et al. Impact of Treatment of Opioid Dependence on Fatal Drug-related Poisoning. Addiction. 2016 Feb; 111(2): 298–308.
MAT is widely regarded as the best practice standard of care for opioid use disorder. The following resources provide more information about the clinical effectiveness of medication-assisted treatment; tools and trainings available for treatment professionals; and where to find MAT services in WA State.
- Medication Assisted Treatment for Opioid Use Disorders: Overview of the Evidence. UW Alcohol & Drug Abuse Institute
- Medication Assisted Treatment for Opioid Addiction. National Institute on Drug Abuse
- Mortality risk during and after opioid substitution treatment: systematic review and meta-analysis of cohort studies. The BMJ.
- Methadone Treatment in Criminal Justice American Association for the Treatment of Opioid Dependence
- The Case for Eliminating Barriers to Medication Assisted Treatment Legal Action Law Center
- Advocating for Your Recovery: What to do When Ordered Off Addiction Medication Legal Action Center
- SAMHSA’s Treatment Improvement Protocol 63: Medications for Opioid Use Disorder has information for addiction professionals about how to talk to patients about these medications, and how to work effectively with healthcare providers.
- Substance Abuse and Mental Health Services Administration MAT website
- Provider’s Clinical Support System for MAT
- ASAM National Practice Guideline for the Use of Medications in the Treatment of Opioid Use Disorder
MAT services in WA State
- Directory of Certified Chemical Dependency Services in Washington State
- Licensed buprenorphine providers locator (Not all providers may be listed. Confirm with the WA Recovery Helpline 1-866-789-1511.)
Opioid treatment programs (OTP)
The Substance Abuse and Mental Health Services Administration officially endorsed overdose education and naloxone distribution in opioid treatment programs in its 2015 Federal Guidelines for Opioid Treatment Programs.
In particular, SAMHSA recommends:
- “Overdose prevention, including prescribing or dispensing naloxone, is an essential complement to both detoxification and medically supervised withdrawal…” (p.24)
- “Because of the risk of fatal overdose if relapse occurs, medically supervised withdrawal services [both voluntary and involuntary] should be accompanied by relapse prevention counseling, overdose prevention education and naloxone prescription.” (p.26)
- “Patients known to be using benzodiazepines should be counselled as to their risk [of overdose] and provided with overdose prevention education and naloxone.” (p.38)
- Treatment orientation should include “signs and symptoms of overdose, use of the naloxone antidote (prescriptions should be given to patients on entry into treatment) and when to seek emergency assistance.” (p.42)
Overdose prevention and naloxone training for individuals who take methadone can be successfully implemented in a variety of ways:
- Overdose risk assessment upon intake
- Patient education (1-1 or groups) on how to prevent, recognize and respond to an overdose
- Dispensing or prescribing naloxone
- Collaborative monitoring of patient dosing medications and prescriptions from other healthcare providers
- Relapse prevention counseling
- Training for staff on how to recognize and respond to an opioid overdose, including administration of naloxone.
If your program wants to integrate overdose prevention into its service delivery model, here are some helpful resources:
- Opioid overdose prevention with intranasal naloxone among people who take methadone. Describes the implementation and outcomes of an overdose education and naloxone program among people taking methadone.
- Overdose Prevention and Management in OTPs. Lessons learned from implementing overdose education and naloxone in an OTP.
- Strategies to Address Barriers and Concerns with Overdose Prevention and Naloxone in OTPs. Responses to common barriers faced by OTPs when implementing overdose prevention.
- Sample naloxone protocols for OTPs