AMERSA Talks

Emerging Overdose Detection Technologies and Hotlines

• Rebecca Northup • Season 1 • Episode 8

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Episode 8 - Emerging Overdose Detection Technologies and Hotlines

Featuring:
Ju Park, PhD MHS
Assistant Professor of Medicine (Research)
Director of Harm Reduction Innovation Lab

Stephen Murray, MPH, NRP
Director, Massachusetts Overdose Prevention Helpline
Harm Reduction Program Manager, Boston Medical Center
 
Host:
Ricky N. Bluthenthal, PhD
Distinguished Professor of Population and Public Health Sciences, Keck School of Medicine, University of Southern California
Associate Director of Institute of Addiction Sciences, USC

Most people who experience a fatal overdose are alone at the time of use and death (solitary drug use). Real-time monitoring of drug use events and rapid connection to a peer responder or Emergency Medical Services could save lives if widely available. This podcast will describe the rationale for remotely supervised drug use via overdose prevention technologies and hotlines and provide examples for how these programs are working in the United States.

Find us online at amersa.org, and see our tweets at x.com/AMERSA_tweets.

Funding for this initiative was made possible by cooperative agreement no. 1H79TI086770 from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services; nor does mention of trade names, commercial practices, or organizations imply endorsement by the U.S. Government.

Learn more about PCSS-MOUD at pcssnow.org.

Kinna Thakarar:

I'm Kinna Thakarar and welcome to the podcast series, Harm Reduction, Compassionate Care for People Who Use Drugs. Harm Reduction is a social justice movement started by and for people who use drugs, and it's a philosophy of care and practical set of strategies to optimize people's health, safety, and rights. We want to acknowledge and honor the long history of street medicine and healthcare developed by people with lived and living experience to keep one another alive and safe through community care. Whether you're a seasoned harm to the concept, we're glad you're here and hope you'll learn something new and are curious to explore seeing patient care through a harm reduction lens. This podcast series is brought to you by the Providers Clinical Support System, Medications for Opioid Use Disorder Project, and AMERSA.

kinna-thakarar--she-her-_4_05-24-2024_134040:

This week, we welcome Dr. Ricky Bluthenthal in conversation with Stephen Murray and Dr. Ju Park to discuss emerging overdose detection technologies and hotlines. Our host, Ricky N. Bluthenthal, PhD, is the Associate Dean for Social Justice and Vice Chair for Diversity, Equity, and Inclusion, and a distinguished professor in the Department of Health population and public health sciences in the Keck School of Medicine at the University of Southern California. His research has established the effectiveness of syringe service programs, tested novel interventions and strategies to reduce HIV risk and improve HIV testing among people who use drugs and men who have sex with men, documented how community conditions contribute to health disparities, and examined health policy implementation. Stephen Murray, MPHNRP, is an overdose researcher, harm reduction program manager, and the director of the Massachusetts Overdose Prevention Helpline at Boston Medical Center. He is a retired lieutenant at a large regional ambulance service in western Massachusetts and has served as a first responder since 2013, having worked both as a firefighter and paramedic. He regularly shares for a national audience about his lived experience as a person who used drugs and an overdose survivor. SIRM provides expert technical assistance around the topics of overdose prevention, emergency medical services, and harm reduction to a variety of organizations, county, and state governments across the country. Dr. Ju Park is a substance use epidemiologist who conducts community based research on substance use and harm reduction. Dr. Park's team, the Harm Reduction Innovation Lab, works to promote the health and well being of people who use drugs by implementing and evaluating interventions to reduce overdose stigma and other negative outcomes associated with drug use. The presenters reported nothing to disclose. Thanks for joining us, Ricky, Ju, and Stephen.

Ricky Bluthenthal:

Thank you, Kina, and welcome, listeners. It's great to have everyone here. I'm your host, Ricky Bluthenthal, and we have a real treat in store for you today, where we're going to talk about emerging overdose detection technologies and hotlines. Over the next 30 to 40 minutes. You'll hear from two experts, Stephen Murray from Boston and Ju Park from Rhode Island who have both been involved in remote sensing activities and overdose prevention efforts for decades. So why don't we get started with you, Ju. How prevalent is solitary drug use and what are the associated risks, especially concerning fatal overdoses?

Ju Park:

Thanks, Ricky. It's great to see you again. So when we talk about solitary drug use, we're thinking about using alone. So that's the More common phrase that might be more familiar to your listeners. We don't unfortunately have any national estimates, but we know that using alone is really common. When you look at survey data collected from different cities and towns across america About 50 to 75 percent of people who use drugs Report using alone at some point in recent times. And so it is a fairly common thing. And when we look at these numbers, we know that the risks are great when there's no one around to monitor you to call 9 1 1 to administer naloxone. You are definitely at higher risk of an overdose.

Stephen Murray:

Just to add into that as well. I think from back to my own, use, and I would say the vast majority of my drug use was alone and like that seemed very normal to me at the time. There's a lot of really important sort of societal and structural reasons why people choose to use alone. And if we don't acknowledge those reasons, we can't understand interventions to meet them where they're using to quote Kim Powers. So like, I think about if you're afraid that your family's going to find out that you're using you would use alone in the bathroom if you're staying with your family in order for them not to find you. If you're afraid that your job's going to find out that you're using and you work at a restaurant, you may go use in the walk in freezer to avoid being detected. So people are using alone, but often it's close by to others that could be available to them in an overdose. If they, one, didn't feel stigmatized enough to the point where they had to be alone. Or two, if they knew that the overdose was occurring. And so I think part of what what you and I are doing is exploring how to fill that gap of like the person is alone. They may be near somebody or they may be near first responders yet without knowing that that person is there or in need-- they're not having their overdose reversed.

Ricky Bluthenthal:

There's another piece to that, which is the sort of structural economic immiseration that can often follow hand in hand with chaotic substance use where people find themselves in S. R. O. S. Right. So a lot of the early studies At least on the West Coast about fatal overdoses, vancouver and San Francisco found that people who were low income and staying in single room only hotels were at elevated risk of fatality. So let's get into the nitty gritty about these real world interventions. So Steven, why don't you tell us what you've been up to?

Stephen Murray:

Yeah, sure. So I, Was involved with this overdose hotline going back into early 2020 at the time that was really sort of pertinent that we think about folks who are isolated and using alone because COVID was rearing its head and we were seeing unprecedented amounts of social isolation across the board. At that time I was still working actively as a paramedic, and quickly saw we were having an increase in fatal overdose. I had heard about the Never Use Alone hotline, I think through Facebook, and that got me interested in this concept. And so I helped to start up the Never Use Alone Massachusetts line, which has gone on to become This line that we operate now, which is the Massachusetts overdose prevention helpline. We are state funded through the department of public health here in Massachusetts. We operate a 24 hour service that hangs out with people on the phone while they're using drugs alone. And in the rare event that they overdose, we're able to get help to them. We just had our 10th 911 activation a couple of nights ago. I guess over the last year and a half. But we've supervised more than 2, 200 solitary drug use events in that time. Across all of the overdose detection hotlines that exist, and there's a few of them in the U. S. and Canada, I think there's been more than 400 overdoses reversed, which You know, while we feel like it's not an intervention that's really been scaled to the population level for those 400 individuals, that meant that they're still alive. That's deeply meaningful to me to be part of that work. We haven't really had the chance to see it work at a bigger level because we're only just the first place to get funding really here in the U. S. to try to do it on a bigger scale.

Ricky Bluthenthal:

And then the peers play an important role in your program, right, Stephen? Can you talk about that?

Stephen Murray:

Our entire model is peer based. So almost all of our operators, we've got almost 30 of them at this point, are either people with lived or living experience or have a very close connection to substance use. Most of the ones that don't have direct lived or living experience actively work in harm reduction programs. They're working with folks who use drugs every day, in their day jobs and then they're coming home at night and answering the phone for us. They're really experienced working with our population, but we actually have people sort of across the spectrum of use from occasional, infrequent, recreational, up into people who are cycling in and out of more chaotic use, up into people who are in recovery. Which can look different for different people, whether it's through, their own pathway or like a California sober, or they're in 12 step we see like all different stuff in our operator pool. And as we move our way up our chain both our full time operators have lived experience in some way. And then I, myself as the director also have, lived experience with overdose and drug use. It's really integral to our model that the folks that answer the phones. Either have been there or are there. Understanding what it's like to, to be in a situation where you're using alone and offering support in the way that they would maybe feel like they would want to be supported.

Ricky Bluthenthal:

Cool. Thank you. So we know research can play an important role in getting these sort of harm reduction strategies accepted and then sometimes disseminated. So what motivated you in particular to get involved with this remote supervised drug use intervention research?

Ju Park:

Well A couple of years ago, I was a naloxone trainer in Baltimore, and we were invited by a parent group out in the county, rural Maryland, to give a naloxone training and at the time, I hadn't thought about the issue of solitary drug use, but a mother came up to me afterwards and told me that her daughter had recently passed away in a bathroom of a rehab. And that, yeah, made me think. Oh, how common is this? And, you know, looking at the surveys that have been done, it seemed like a very common problem that was not really being discussed. And as Stephen mentioned COVID personally, I think all of us felt the isolation and could understand why substance use might have been increasing. I was invited, fortunately, by the Cobrae on opioids and overdose to an event where. An EMT by the name of Stephen Murray gave a fantastic presentation about the New England hotline. So that was a couple, I think now three years ago. And, also met Gordon Casey from Brave Technology Co op, and others doing similar work and as a harm reduction researcher, I'm always looking at interventions that communities really appreciate, interventions that communities developed themselves, and that's really, at the heart of these Overdose technologies that we are piloting and evaluating in Rhode Island

Ricky Bluthenthal:

Stephen has outlined the hotline method, which is a little bit labor intensive. But effective. Have you explored some of these other things like motion sensors or Can you talk about that a little bit?

Ju Park:

So we recently did a literature review and, found that there are maybe three groups. Telephone hotlines are one group of interventions. The second group fixed site interventions, such as, reverse motion senses, buttons that can go either on a wall or a ceiling of a building to help detect overdoses in real time and alert nearby responders. And then the third, mobile or wearables. There are a number of apps, but also watches and other tools being developed, that are a little more, technology heavy. At the same time, doing this work, it's very clear to me that none of these tools really work without the support of community members, without buy in the, the stigma around substance use is so real this housing issue thank you program that I recently visited, the patients that told me that they like the idea of these tools, but it's a real fear that the police are going to show up if they overdose, or they're going to get kicked out of housing as you know, it's, it's been shown, in other studies too and then also the loss of custody of children, and that's another real barrier. Some of these policies that we have inadvertently causing or perpetuating the problems that we're trying to solve. It's an interesting space to be to do this work well, I think we need to move on all fronts, the technology side, the scientific evaluation side, but also the policy side of things.

Ricky Bluthenthal:

Well, that brings up, the concern about ethical issues. So, Stephen, can you talk at least from your experience about what are some of the ethical considerations that come up with implementing these remote supervised drug use interventions?

Stephen Murray:

There's a couple of different major considerations from an ethical standpoint. The first of course, comes down on the to the technology side, which is is the technology secure, are the data secure that are being collected, because we do still live in a highly criminalized prohibition laden society where, Law enforcement does have a vested interest in criminalizing folks who use drugs. As you really rightfully pointed out, criminalization is at the forefront of the minds of our callers. And so it needs to be at the forefront of our minds and criminalization comes in multiple forms too. I mean, we support parents who use drugs, we're worried about criminalization in the form of Child Protective Services. That's just another example. Housing is, policed in some way, where people are afraid that if we activate the 9 1 1 system for them, they may lose their housing. One of the most disturbing things that we ever heard on a hotline call was somebody telling us that they were more afraid of losing their housing than they were of dying from an overdose. That is a really grim reality for folks that are, they're having to make that value decision. Before they pick up the phone to call us, they're thinking, am I going to die if I don't use the service? If I use the service and I don't die, does that mean I'm going to lose my kids in my house? Like that is not a really great place for people to be starting at. When they're trying to make a decision that is about improving their health. So that's really the first ones. How do we keep people's information secure? How do we keep them as safe as possible from some of the other prohibition related harms that are out there? We take that really seriously. We don't collect any personal identifying information about people. The only location data that we keep is zip code. Which we can even further, obscure or randomize if needed. Then all of our data are kept in a red cap database, which has very little identifying information. We also do record calls mostly for the safety of our callers, and operators to make sure that our rules are being followed and operators aren't putting callers at risk and that callers aren't also in turn harming operators. But we've gotten much more aggressive in our call recording retention policy. We now have calls deleted within seven days and sometimes even sooner than that. Once they've been reviewed by our quality team to make sure that nothing out of the ordinary happened. It's a personal goal of mine to get that under 72 hours within the next six months. But part of that is scaling up our staff a little bit to make that a possibility. The other thing is that, We've put a lot of things in place on the same vein of like protecting callers and operators is that there is a lot of trauma bonding that happens with folks when they're talking on the phone regularly. A lot of our callers are repeat callers. They call every day, multiple times a day, 10 times a day. Every time they use, which is what we want, but they do get to know the operators. And so we do have pretty strict rules about exchanging personal information between operators and callers in order to help protect some of those boundaries and keep things as appropriate and professional as possible. So there's a lot at play there. We have a code of conduct that our operators have to initial and sign and there's like 20 items on there. I had a reflection from a recent operator who came on was like, let me guess, all 20 of those things are things that have happened on the line that you're now accounting for. And, and they're absolutely right. It didn't necessarily happen on our line, but we all talk, all the different hotlines talk, so we know when something happens on one line, Oh, we better secure up and not make it happen here. There's a lot that goes into making sure that this is done safely and professionally for everybody involved.

Ricky Bluthenthal:

So let me ask you a question. There is a line of thinking in the world that suggests that anything you do to keep people who are experiencing chronic substance use disorder alive is problematic or enabling somehow, have you addressed that in your research and what's your response to that concern?

Ju Park:

Yeah, that's the gut reaction a lot of people have when they hear about harm reduction for the first time, the concept of keeping people safe, supporting them, even if we don't agree with all of their choices. Somebody mentioned at a conference recently that actually Stephen and I presented it-- when it comes to evaluation, does it really matter if you only reverse, 10, 20, 50 overdoses? And my response to that line of thinking is that in my opinion is that every life matters, but when we think about people who use drugs as humans, as relational beings, that is someone's, you know, daughter, son, grandchild, that is someone's father, mother.... I think maybe my experience is a little different because I have lost friends to overdose, but actually it shouldn't be that different because according to a national study that was published recently, 40 percent of Americans know someone who has died of an overdose. The stigma is real but from a harm reduction perspective, we need to be keeping people safe and treating this like a health crisis, values and morals aside the goal really is to reduce harm the harms, the social harms, the health harms, the economic harms, costs over a trillion dollars to the US economy every year. So I really hope that people who have that reaction to patients with substance use disorders really think about, like, where does that line of thinking come from? Is it something that we truly believe or is it something that we've been taught or our society imposes upon us?

Ricky Bluthenthal:

Let me just follow up with you then. So in keeping that in mind how do you approach evaluating these programs? What are the things that you're looking to see change or happen over the long term would evaluate whether these are effective or not?

Ju Park:

We really want to show the impacts, not just to overdose numbers. Overdose numbers are important, but there's a lot of stress and burnout that happens in community organizations specifically. For example syringe exchange programs or housing programs, the staff are wearing multiple hats, doing 20 things at the same time and checking on the bathroom every 2 to 5 minutes. It's a burden. One of the things we're hoping to show is that these tools could help alleviate some of that burden and cognitive stress. Right now, the study we have in Rhode Island is only 12 months and has only a few sites. We are actively working to secure longer term funding. And I think that's That's where we are headed and that's what we really need because these interventions, tools, whatever you want to call them, take a long time to really be implemented and adopted. Even the Never Use Alone Hotline, it's been around since 2020. When we go out and ask people, Hey, have you ever heard of the Never Use Alone Hotline? A lot of people have never heard of it. The longer term studies of what's really going to help us understand what's going on and what's going to be most effective.

Ricky Bluthenthal:

I like that you brought up the workforce implications. One of the things I hear and Stephen describing the hotline that he runs is the relationship building piece, which is obviously really positive, but it can have this cognitive and emotional burden for the people who work in that space. So I wonder, and this is something for the other people listening to this to think about is what are ways to reduce that space in your community between people who have substance use disorder and are at risk for overdose death and the isolation that comes with that. Something to think about and maybe we can return and reflect on that towards the end. so let's turn to the, this American life episode eight or nine that I'm happy to report had me crying at the end of it's very moving, And really, in my 30 years of experience in the harm reduction movement is probably the best distillation of what harm reduction can do. So, Stephen, can you talk a little bit about, how that all came to be? And what's up with the folks that were including yourself that were featured in that episode?

Stephen Murray:

Sure. And thanks, Ricky. I'm glad it was so meaningful to you. To the AMERSA audience listening, the things that people came up and said to me at the conference in November, really deeply meaningful. I'm glad that people felt heard by what we did it's 1 of the most special things that I've had happen to me in this work so far, having our peers, like, in this space feel like the people around them understood them better through that episode. It came about in a weird way. I think the way it started was that mary Harris from Slate went down to Georgia with photographer and reporter to see Jesse and to learn about Jesse's work. And while they were down there, Jesse was taking hotline calls, and they got onto the story of Kimber, because it's a very, if you heard, it's a very, interesting story because we were all sort of brought together in that moment, and they were like, oh, we want to tell that story too. And so they actually went and pitched it to This American Life and it became a collaborative effort between Slate and This American Life. It's now won a Writer's Guild of America award. For best audio documentary this year. It just won last week. It also won a Gracie award, from the Women's Foundation, which is really, it's just really special that it's being recognized on the national stage. It was intense. I think I have about 20 minutes of audio in it and that came from like six and a half hours of interview time. It became what it is, which is we think somewhere between six and 8 million people listen to this American life. It was one of their bigger episodes, I think of the year. It's been heard around the world. When I was at the conference, the INSU conference, which is the, the International network for hepatitis and substances. People from Australia had heard it. it has an impact on the international harm reduction community as well, which is again, it's like, just really humbling and special. In terms of what's going on everyone's doing well. Kimber works for the mass overdose helpline. She's our frontline operator. She's a full time salaried employee of Boston Medical Center and just an amazing spokesperson for the work that we're doing. She regularly joins me giving talks. I'm sending her off on her own now to do talks as well, which she does scarily well, for someone who has like no media training.. The other thing is that Jesse also is working with us on the hotline. So she takes calls for our hotline as well. We're also scaling her up into a mentorship role where she's working with new operators. To help them be better operators because nobody does it better than her. She's the, she's the best operator in the world. As you heard on the phone, like she just does it with such ease and grace, and so we're all doing really well. We talk regularly. I owe Jessie B a call probably, yeah, it's really great to still be involved with them. What does it mean to, the harm reduction community it's it is a view into what at our very core we're trying to do, which is to keep people safe and give them the autonomy to make decisions about their own health and to, like, help them to make those decisions however they see fit. It's just about one person caring about another person and being there for them without other preconceived ideas or ultimatums. A lot of us who've been in chaotic drug use, we're used to everybody around us giving us ultimatums about our use or demanding that we do certain things or, or putting us in places against our will. So in harm reduction, we take an opposite approach, which is just to, to love people and help them to make decisions that feel good for them. I think that's a beautiful thing.

Ricky Bluthenthal:

Well said. What do you think in terms of, returning to this idea of the stigma itself an independent variable in fatalities related to substance use disorder. What are some other things that we could do, whether it's in the remote sensing world or others that would address those challenges?

Ju Park:

Repairing relationships between people some people, when we ask, you know, why did you use alone, say it's because there is no one else. A lot of people have turned their backs on them. Finding ways to help people create meaningful relationships or repair those relationships, I think will be really important. And then something basic like naloxone coverage. We still are seeing not enough naloxone in the hands of people who could respond, and more innovative interventions, like nalox boxes and naloxone vending machines-- I think those are really exciting. Then also just doing outreach in non traditional places. So we've been going to fast food restaurants, gas stations, libraries, gyms, places that don't usually get targeted by harm reduction interventions and organizations, but are also places where either they see overdoses on site or they encounter people who may benefit from naloxone training. So I think all of those things can really help. Lastly, I would say that, lot the organizations that come to us and evaluation team for help often say we know what works. We know what we're doing. It's just we need help showing that it does work. And sometimes that's for their funders. Sometimes it's for reporting purposes, or sometimes it's to build support in their community because they get a lot of pushback. Where evaluators, researchers can really help is by working with the community members who are already doing the work and finding ways to support them rather than coming up with fancy solutions and just implementing them wherever they want to without the community support.

Ricky Bluthenthal:

I just want to highlight again the hotline and the people involved in that are of a long line of people who use drugs, designing programs that are sustainable and effective at preserving life. And really what they need is just the resources to bring it to scale. In Los Angeles County where I am, there's been a real local level initiative to Build out a harm reduction infrastructure and that they're spending I think it's about seven or eight million dollars a year now so they're building these case studies of people who've gone from chaotic use to maybe a recovery home to maybe A job and a lot of those cases have this issue around reconnecting with family one of the first things that people want is that reconnection and it brings to the surface That in some ways it's a bit of a horror, right in terms of we're told Oh, you know shut them off cut them down don't enable them, and in fact There seems to be emerging evidence that that that kind of approach Just makes it worse for people and the answer is actually community and relationship.

Ju Park:

You just reminded me of something that Una Creek from Brave said to me very early on, which was that these technologies are about building connections. We had this whole philosophical debate about how the use of social media and cell phones, and even, Netflix subscriptions have actually caused us to be more independent and more isolated. And so, isn't it funny that technological tools could actually be used to form those connections? I totally agree with what you just said. And you just reminded me of that.

Stephen Murray:

I can just add to that too, that, I often get asked why I was able to pull myself away from chaotic drug use and can't really put my finger on it besides, immense privilege and also that I wanted to stop using was a big part, but also like my family never turned their back on me and I never lost that connection. I always maintained my own community, at least with my family. I have my mom, to thank for that. And my sister, my sister has actually devoted her life to working with families to do that, with a nonprofit that she runs, where they're working with families as well. I think that that is a really important part of this connection and, and why I'm still alive. If you're ever at that crossroads where you're wondering, do you cut your family off or not? Well, you can hear at least from me that the the reason i'm still alive is that my family stuck by me even when things were pretty bad.

Ricky Bluthenthal:

Let's end on this note then and i'll quote the famous stephen murray the answer to compassion fatigue is Compassion. Well, thank you both very much for sharing your experiences and innovations that you brought to this field and and all the great work that you're doing.

kinna-thakarar--she-her-_5_05-24-2024_141616:

That was Stephen Murray, Dr. Ju Park, and Dr. Rikki Bluthenthal in conversation on harm reduction, compassionate care for people who use drugs. Thank you for listening.

Kinna Thakarar:

Please take a moment to complete SAMHSA's post event evaluation survey on the AMERSA podcast page at www. dot AMERSA dot. Org forward slash harm reduction podcast. We welcome any comments, questions, or other feedback for presenters. You can send those directly to AMERSA through the contact us form at AMERSA. org. To learn more about the provider's clinical support system, Medication for Opioid Use Disorder Project, and AMERSA please visit our websites at PCSSMOUD. org and AMERSA org. Funding for this initiative was made possible by Cooperative Agreement No. 1 H 79 TI 086 770 from SAMHSA. The views expressed in written conference materials or publications and by speakers and moderators do not necessarily reflect the official policies of the Department of Health and Human Services, nor does mention of trade names, commercial practices, or organizations imply endorsement by the U. S. government.