As a result of COVID-19 restrictions, the Rensselaer County Department of Health (RCDOH) launched the Naloxone Now program in April 2020. There was a dramatic increase in fatal and non-fatal overdoses coinciding with the initiation New York State social distancing and business closure mandates. We recognized the need for resident to have access to Narcan, but we were unable to provide Narcan trainings in the traditional didactic manner due to the social restrictions. Naloxone Now was created to provide Narcan training and kits to individuals while adhering to social distancing restrictions.

             The process begins when an individual texts the word "Narcan" to 21000. The individual will then receive an automatic reply with a link to a form to request a Narcan kit. The form asks for demographic information as well as past experience using Naloxone and additional needs.

      Four staff members from the Health Department receive electronic notification of a Narcan request immediately after submission. The completed electronic request form sent to staff includes a link to Approve or Reject the request. When the request is approved by one staff member, a notification is sent to all participating staff, which allows the other staff to know who will be fulfilling this request.

A RCDOH staff member calls each submission to complete Narcan training with the individual over the phone and arrange drop off of the Naloxone and accompanying materials. The no-contact delivery is typically executed by placing a bag with the Narcan and accompanying materials in the resident's mailbox, on their porch, or on the front doorknob. In addition to the Narcan, requestors receive disposable gloves, a rescue breathing barrier, a fentanyl test strip, a deactivation bag, and informational materials for access to local recovery and harm reduction services. The deactivation bags are included primarily so if a test strip indicates fentanyl is present the individual can safely dispose of the substance.

 Should an out-of-county resident request Narcan, RCDOH staff will call and inform the individual of Narcan resources in their area or offer the individual the opportunity to come to the Health Department to receive a kit.

As of 11/12/2020, the Rensselaer County Department of Health has fulfilled 103 Narcan Now requests since the first request received on 4/07/2020. Most kits were delivered within 24 hours of the request. In addition, our Health Department has provided two nearby counties with assistance in initiating their own contactless Narcan delivery programs.

Rensselaer County has not been spared from the current opioid crisis devastating the country. From 2012-2019, Rensselaer County lost 169 individuals to overdoses. Rensselaer County began the fight against the opioid epidemic in 2016 with the creation of the Rensselaer County Heroin Coalition. As a means of community harm reduction, the Rensselaer County Department of Health (RCDOH) became a New York State Opioid Overdose Prevention Program (OOPP). As an OOPP, Rensselaer County can provide Narcan training and kits to the public, an evidence-based practice to reduce opioid overdoses that is recognized by the CDC. The RCDOH community training events have been offered monthly, as well as trainings for community agencies. Our program also provides Narcan kits for trainings completed by the Rensselaer County Office of Mental Health’s Certified Peer Recovery Advocate (CRPA). In 2019, over 900 individuals were trained in Rensselaer County through these means.

Statewide social restrictions were placed by Governor Cuomo on March 16,2020 as the COVID-19 pandemic began spreading through Upstate New York. Individuals became increasingly isolated and treatment providers struggled to maintain contact without physical visitation. Unemployment  rates increased. Access to substances of choice were limited or altered by the pandemic. As a result of various pandemic-related factors, we saw a dramatic increase in fatal overdoses in our County. From March 16th-March 31st, in less than two weeks, we lost 5 individuals to overdoses. Thus far in 2020, Rensselaer County has lost 60 individuals to overdoses, compared to 34 fatal overdoses in 2019.

In addition to the demographics we typically see among opioid overdoses, two new populations began to emerge. A number of white middle-class recreational cocaine users fatally overdosed due to the presence of fentanyl in their cocaine. These individuals had been using cocaine recreationally for years without consequence, and were not aware their cocaine had been cut with fatal levels of fentanyl. We also saw an increase in fatal overdoses among crack-cocaine users. As with powder cocaine, crack cocaine in this region was also laced with fatal levels of fentanyl.

Due to the widespread social restrictions to prevent the transmission of COVID-19, the RCDOH could no longer provide public Narcan trainings and the CRPA was unable to distribute Naloxone. Prior to COVID-19, Narcan trainings by NYS OOPPs were only permitted to be provided in-person. Our Public Health Director quickly recognized the need to get Narcan into the community without physical contact and in late March 2020, the RCDOH received permission from the State to provide Narcan through the curbside delivery and telephonic training.

In response to the community need for contactless Narcan training and kit delivery, a staff member created a program using a texting platform that would allow residents to enter their information to request free curbside delivery of Naloxone, without physical contact. The texting platform, Txt180, requires a monthly subscription fee. Through Txt180, we were able to choose a keyword to apply to the phone number 21000.  The keyword chosen was “Narcan.” When an individual texts the word “Narcan” to 21000, they receive an automatic reply with a link to a form to request Narcan from RCDOH. The form asks for demographic information, delivery address, if there are additional needs, and if the kit will be a replenishment.  Individuals who choose not to disclose their true name or age are not excluded from receiving Narcan. Our Health Department's priority is harm reduction and universal access to Narcan.

Along with the prevention of transmission of COVID-19, this service allows us to provide Naloxone to residents who may otherwise face barriers to receiving Naloxone. A 2018 survey of the Capital District, including Rensselaer County, found that transportation was the top barrier to care reported by residents. The Health Department can now deliver Naloxone to the outlying rural areas of the County that are more than forty minutes from a main city. Kits are also requested and delivered to inner-city residents who want to avoid the public transportation they typically rely on. Naloxone Now allows us to reach more residents than by traditional training programs. We now offer training and the provision of Narcan kits outside of typical business hours, which benefits a working population who may have had difficulty participating prior to COVID-19. The option for anonymity that Naloxone Now provides is an incentive for individuals to receive Narcan training who had previously declined participation to protect their privacy. Due to the broader reach afforded by Naloxone Now, the RCDOH intends to continue this program after the pandemic’s social restrictions have been lifted.

In May, Naloxone Now, became highly utilized by residents following an overnight spike in fatal and non-fatal overdoses. On May 20th, Rensselaer County experienced a total of 14 overdoses, 2 of which were fatal. The next morning, Rensselaer County officials provided a public broadcast via Facebook Live © to warn residents of the fatally- laced drugs. Naloxone Now was advertised as an option for residents to obtain Narcan and fentanyl test strips to reduce the likelihood of experiencing a fatal overdose if they possessed drugs from the laced supply. From May 21st  through May 25th, Rensselaer County distributed 73 Narcan kits and 81 fentanyl test strips to residents, 55 of which were requested through Naloxone Now. Naloxone Now was first advertised via the County Facebook © page. PDF flyers were posted with a brief program description and contact information. A business card with the Naloxone Now text request number was created in April 2020. All 72 first responder agencies within the County received a pack of the cards to distribute on overdose calls. The Naloxone Now cards were provided to several local outreach agencies. The County has ordered disposable coasters with the Naloxone Now request line that will be distributed to local restaurants. The coasters will be accompanied by a letter signed by our County Executive and Public Health Director explaining the current overdose crisis in our community and requesting business owner participation in utilizing the coasters.

The primary goal of Naloxone Now was to reduce the surging number of fatal overdoses within our county. The Naloxone Now program initially began to form as a result of the Public Health Director seeking a way to replenish residents’ Narcan kits after use. The idea quickly evolved into a broader program that would allow us to get Narcan, the life-saving opioid reversal medication, into more households within our community. We had to train and provide the Narcan kits in a manner that was safe for both our staff and residents.

The staff member who assisted the Public Health Director with the innovation of the program also works as an EMT for a local ambulance company. His experience as a first responder provided helpful insight into the program’s design. This employee suggested using a platform that would allow any resident to request Narcan, with an option to note if it was a replenishment. The employee researched potential methods of receiving requests for Narcan and brought the suggestion of a texting platform to the Public Health Director.

The staff member executed all technological features of the texting platform. He claimed the prompt “Narcan” for the platform’s phone number. He customized the automatic reply to the initial text request that would provide the link to the full request form. The request form was also created by the staff member. The form obtains not only demographic information, but also provides options to request information about additional local resources. There are opportunities for further education including videos relating to Narcan administration.

After an individual completes the request form, participating staff are automatically notified. Arrangements are made for a staff member to train and deliver. The individual will be called by the designated staff member for a telephonic training and to arrange for drop off. Most kits are delivered within 24 hours of a request. The kits are provided at no cost to residents, as they are provided through the NYS Opioid Overdose Prevention Program.

Txt180, the texting platform, stores all information received through the request number. This feature is not only helpful for data analysis, but allows us to investigate requests that may have been incomplete. There have been some individuals who will send the initial “Narcan” text, but will not complete the request form that is sent as an automatic reply. We can see the phone number of the incomplete requests and follow up with them directly to ensure they will receive Narcan, although they didn’t complete the form.

In the first week of April, after RCDOH officially launched Naloxone Now, packages were prepared with a letter from our Public Health Director and a pack of Naloxone Now business cards advertising the text line and free, contactless delivery of Narcan. The letter detailed the local spike in fatal overdoses. The letter included a description Naloxone Now and encouraged dissemination of the program business cards on overdose calls. All 72 emergency response agencies within the County received these informational packages. We received a call the following day from a local police department requesting more business cards to keep in every patrol car.

Several local community outreach agencies, grocery stores, and gas stations agreed to distribute or display the Naloxone Now cards. One of the local outreach agencies serves the homeless population. There have been instances when outreach staff used their own phone to request Narcan for the individual they are serving who does not own a phone themselves to place a request.

The County has ordered disposable coasters with the Naloxone Now request line that will be distributed to local restaurants. The coasters will be accompanied by a letter signed by our County Executive and Public Health Director explaining the current overdose crisis in our community and requesting business owner participation in utilizing the coasters.

As previously described, Naloxone Now was created with community prevention and harm reduction in mind. With a rise in overdoses coinciding with community spread of COVID-19, more residents desired Naloxone, which needed to be provided safely. The delivery component of Naloxone Now allows us to address health equity by serving those who are confined to their homes. In addition to the pre-pandemic barriers to care for individuals including; physical mobility, transportation, and child care, COVID-19 kept many more individuals within their own homes. Many residents who are immune compromised restricted their activities outside the home to a greater extent in attempts to avoided contracting the virus. Naloxone Now allows our Health Department to provide this opioid overdose-reversal medication without any vulnerable populations risking an exposure to COVID-19.

The Rensselaer County Department of Health had most of the necessary resources in place to implement Naloxone Now. The time and mileage reimbursement allotted for hosting community Narcan trainings was easily reallocated for Naloxone Now’s individual telephonic trainings and Narcan deliveries. Through the NYS Opioid Overdose Prevention Program, we had the Narcan kits and State permission to distribute through delivery. We had bags and the educational materials that would normally be distributed to participants in a community training. A previous grant had allowed us to purchase rescue breathing barriers and disposable gloves. We also include palm cards for the Rensselaer County Recovery Helpline. The Helpline is available 12 hours a day, 7 days a week for people in recovery and their families, as well as for education, resources, and/or linkage to care.

 Prior to the pandemic, the Health Department had requested permission from the Rensselaer County Executive to purchase and distribute fentanyl testing strips. Permission had been granted in early spring, so we were able to include fentanyl testing strips with all Naloxone Now deliveries. In August, we received drug deactivation pouches from the NYS Office of Addiction Services and Supports. The pouches possess chemicals that allow individuals to safely deactivate and dispose of unused, expired or unneeded medications in their own home. The deactivation pouches have since been included with all subsequent Naloxone Now deliveries.

The entire program is anticipated to continue post-pandemic. We have reached a broader resident population through Naloxone Now than we did prior to COVID-19. Naloxone Now allows more households to have Naloxone present as a life-saving measure.