Located in north-central Alabama, Jefferson County contains the county-seat city of Birmingham, the surrounding metro area, and outlying rural area. It is the most populous county in Alabama with roughly 660,000 residents and Birmingham is the largest city in Alabama. The population identifies 52.7% female and 47.3% male. Racial demographics of Jefferson County are 53.1% white, 43.5% black, and 4.1 % Hispanic or Latino (Census, 2019). Languages spoken at home include English only households (94.1%) and Spanish (3.4%). The Jefferson County Community Health Equity Report 2018 shows the county has a higher percentage of people under the age of 65 without health insurance compared to the national average (11.1% vs 9.5 %) (2018). Additionally, the county has a higher percentage of residents living in poverty compared to the national average (17.0% vs 12.3%) (Census, 2019). The majority of the population is between 19-65 years old.   Life expectancy in Jefferson County was 74.4 years in 2017 (Community Equity Report, October 2019). According to the National Center for Health Statistics, the national life expectancy at birth in 2017 was 78.6 years, making Jefferson County’s life expectancy lower than the national average.  Life expectancy for residents of Alabama was 75.5 in 2017 making it almost a year longer that average Jefferson County life expectancy.

The Jefferson County Department of Health (JCDH) is a local health department serving Jefferson County. It operates through the governance of a Board of Health made up of six members: five physicians elected by the Jefferson County Medical Society and the President of the Jefferson County Commission. The Board approves JCDH’s annual budget and all contracts. The Board is authorized to revise or adopt certain public health regulations, endorse policies and legislation promoting health, and take other actions advancing public health. JCDH enlists a variety of programs and services for the community in order to accomplish its listed mission to “prevent disease and assure access to quality health care, promote a healthy lifestyle and a healthy environment, protect against public health threats.” Divisions include child health, family planning, dental health, disease control, environmental health, emergency preparedness, and population health among others.

Echoing the nation, drug overdose is a persistent public health issue in Jefferson County. Though national drug overdose deaths declined in the period from 2017-2018, the trend reversed significantly with an 18.2% increase in overdose deaths in the 12-months ending in May 2020 compared to the 12-months ending in June 2019 (CDC). According to the Centers for Disease Control and Prevention (CDC), over 81,000 drug overdose deaths occurred in the United States in the 12 months ending in May 2020. This was the highest number of overdose deaths recorded in a 12-month period. Alabama ranks among states with the highest increase in drug overdose deaths with a greater than 20% increase in overdose deaths in the 12-months ending in May 2020 compared to 12-months ending in June 2019.  The southeast region of the United States experiences some the highest rates of opioid use with Alabama ranking highest in opioid prescriptions at 85.8 per 100 people (CDC) which significantly exceeds the national average of 46.7 prescriptions per 100 people (CDC).

In 2018, Jefferson County followed national patterns with an overall declining trend in opioid overdose deaths. However, again mirroring national trends, the Jefferson County Coroner and Medical Examiner’s Office 2019 Annual Report showed a 3.5% increase in total overdose deaths from the 2018 to 2019 period, specifically a 1.7% increase in opioid overdose deaths. Opioid overdoses, both from illicit and prescription drugs, represent the majority of overdose related deaths (74%).  In 2019, white males (106 deaths), followed by white females (68 deaths) represented the highest numbers of overdose deaths in the county. Distressingly, Jefferson County saw a 36.8% increase in fatal opioid overdoses from January to October of 2020 when compared to same time period of 2019. From the Jefferson County Department of Health surveillance data, the individuals most impacted by fatal and non-fatal overdose burden are white males aged 30-39. During the COVID-19 pandemic, we are seeing an anecdotal shift in the racial distribution of overdose deaths with increasing numbers of black males with fatal opioid overdoses.

Novel virus SARS COVID-19 presented many problems thwarting traditional models of healthcare delivery. Since 2016 in Alabama, naloxone can be dispensed under a Standing Order from the State Health Officer by a public health registered nurse, a physician, or a pharmacist (HB379). Jefferson County Department of Health has relied on a variety of in-person naloxone training formats ranging from large public awareness days to monthly community trainings as the method to distribute naloxone kits utilizing JCDH qualified staff. Additionally, first responders received in-person training at police and fire departments.  However, as COVID 19 is spread through respiratory droplets and close contact with others, the existing model of in-person training for naloxone distribution and education would not meet social distancing requirements. Jefferson County has had the highest amount of positive COVID cases in Alabama since the pandemic began and according to John Hopkins University, in December 2020, Alabama ranked sixth on a list of states with the highest amount of new cases of COVID per week (Associated Press). Thus, an innovative practice would have to be developed in order to meet the ongoing needs of the community while maintaining staff and client safety.

              As the rate of opioid overdoses rose in Jefferson County, the need for naloxone increased. However, expansion of in-person training not conducive to limit the spread of COVID 19. Thus, the JCDH Population Health and Health Equity Division sought to create an online training platform to fill in gaps created when in-person trainings halted. The online training was designed for individuals and organizations to receive naloxone training and obtain naloxone nasal spray kits via mail order or pick up at a local pharmacy. The target population of the program is the most underserved in our community, including the un-insured or underinsured. As a 2019 sub-recipient of the Center for Disease Control and Prevention’s Overdose Data to Action Grant, we have been able to use data to inform our public health interventions for combating drug overdose. Through use of local and state surveillance data to generate “hot spot” area maps for drug overdose in Jefferson County, we implemented strategic methodology to reach the populations with greatest need. Though there is benefit to in-person training including space for dialogue and development of rapport between audience and trainer, our online training maintained a similar model to the in-person training. A public health nurse practitioner familiar with the training filmed the online training with similar verbiage to in-person training. Individuals had the option of coming to the local health department to arrange a contact-less pickup, pickup at a local pharmacy, or requesting a kit be mailed directly to them.

The Jefferson County Department of Health (JCDH) places strong emphasis on both internal and external partnerships. Launching new or innovative practice requires input and participation from stakeholders in order to thoroughly meet the needs of the population being served and execute it with the tools available from partners.  The goals of the practice were to create a method of naloxone training and distribution that limited the spread of COVID-19 while increasing access to life-saving medication. With opioid overdose deaths in Jefferson County rising 36.8% in the first ten months of 2020 when compared to the same time period in 2019 and exacerbation by the COVID-19 pandemic, naloxone distribution networks previously used were severely disrupted in Jefferson County. This made it even more difficult for special populations and other persons in need to obtain opioid antagonists that may save their lives or the life of a loved one. Our team initially consisted of our Population Health and Health Equity division comprised of a physician director, nurse practitioner, registered nurse, social worker, and interns. Realizing that the existing model of in-person education and delivery would no longer suffice and taking note of the needs of the populations served, the next steps involved assessing the best delivery model for the practice and how to implement it when established. It was proposed to adapt training to an online module. Close internal partnership with the JCDH Management and Information Systems guided the development and steps needed to create a website for online training and completion of form for mail-order kit delivery.

At the time of onset of the COVID-19 virus in the United States, naloxone was available for residents of Alabama through the Standing Order of the State Health Officer and could be dispensed from appropriate personnel. However, there was no state-wide or local mail order free program and cost was frequently an access barrier. The program developed by JCDH is used to deliver free mail-order naloxone state-wide to residents both inside and outside Jefferson County.

              Before starting an online naloxone training and dispensing program, JCDH needed to clarify that dispensing of naloxone via mail was within the regulations of the Alabama Board of Medical Examiners. In 2015 and 2016, Alabama legislature enacted in law provisions that allowed for specific dispensing of opioid antagonists:

A physician licensed under Article 3 of Chapter 24 of Title 34, or dentist licensed under Chapter 9 of Title 34, acting in good faith may directly or by standing order prescribe, and a pharmacist licensed under Chapter 23 of Title 34, or a registered nurse in the employment of the State Health Department or a county health department, may dispense, an opioid antagonist to either of the following:

(1) An individual at risk of experiencing an opiate-related overdose.

(2) A family member, friend, member of a fire department, rescue squad, volunteer fire department personnel, or other individual, including law enforcement, in a position to assist an individual at risk of experiencing an opiate-related overdose.

Ala. Code § 20-2-280(b). Naloxone hydrochloride is an “opioid antagonist” for the purposes of this statute. Ala. Code § 20-2-280(a).

Review by JCDH legal counsel found the statue to be unclear on the issue of physician ability to dispense (or mail) naloxone to non-patients without a personalized prescription. Thus, JCDH requested guidance from the Alabama Board of Medical Examiners (BME) on whether a health department physician, acting in accordance with this statute had ability to lawfully dispense naloxone, without a prescription, to non-patient third parties who are otherwise covered by the statute but would not technically be getting a prescription for themselves. On October 21, 2020, via emergency declaration, the BME approved the dispensing of naloxone to non-patients via mail by a health department physician contingent on completion of the online training.

A new partnership for JCDH involved local, independent pharmacies. With existing relationships in the communities they serve, they are source of trusted health advice. They reported that they could identify patients that would benefit from education on how to recognize and respond to an opioid overdose but the cost to obtain naloxone was often prohibitive. Partnership with local pharmacies was strategic and specifically done with establishments in recognized areas with higher numbers of overdoses in Jefferson County. Pharmacies helped implement the practice by partnership with JCDH by acting as distribution sites for free naloxone and advertising the online training program. Individuals training online have the option of picking up a naloxone kit at participating partner pharmacy. Future partnership opportunities are in discussion with larger chain pharmacies. 

Observed from surveillance data, hotels and motels in Jefferson County emerged as hot spots for overdose. The Environmental Health division at JCDH manages permits and regulation of governing establishments where sleeping arrangements made available for people to stay temporarily. With the internal partnership and support from Environmental Health, JCDH Population Health and Health Equity formed new external partnerships when all hotels and motels located in hot spot areas received a mass mailing informing them of the online training platform. They were invited to have staff receive online training and naloxone kits to insure they could respond in the event of opioid overdose. Though regulatory capacity did not change based on hotels response to letter there was high level of interest from hotel owners and operators to become public health partners and receive naloxone training.

JCDH has spearheaded many efforts to bring awareness to this issue in the community through social media and partnerships. Internal and external meetings with community partners are offered virtually. A task force has been created with leaders from various community organizations to foster collaboration with community stakeholders by enhanced discussion about the increasing overdose rate and methods of naloxone delivery. This virtual meeting is held bi-monthly. Community partners helped implement the online naloxone training by sharing it with their networks. Strategic partnerships were used to address health equity in the program by increased the availability of naloxone to rural and urban community members and working to decrease stigma surrounding carrying naloxone and naloxone use.

Jefferson County Department of Health (JCDH) adapted to the needs of the community by creating a method of naloxone training and distribution that upheld safety and wellness throughout COVID19 but did not limit access to training and kit distribution. Rather than ending the health department’s naloxone distribution program, the JCDH team worked rapidly to set up an online training platform with a hub and spoke distribution model locally and a mail-order order distribution model both locally and state-wide. As the online training website launched, improvements needed to be made to best serve the public. We continually made improvements to the platform to make it user friendly and accessible. The addition of the training tab on the Jefferson County Department of Health homepage insured greater traffic from the general public. Strong internal partnership between the Management Information System division and the Population Health and Health Equity division allowed the website to be updated quickly. Addition of a “how did you hear about us” checkbox was added to the online training platform to gather data methods of reaching the public. A variety of everyday procedures needed to be adapted and adopted to maintain the program. Automatic emails made the Population Health and Health Equity Division team aware that a training and been completed and states the client’s preferred form of kit delivery. Once established, the team prepared the kit for mailing, pickup at the health department, or confirmed with the patient that they will pick up with a local pharmacy. JCDH General Services division helped to create a procedure for mailing the kits. This division oversees the mail and collaborated on our goal to establish a repeatable and trackable process to assure the naloxone kits arrive at the correct destination.

From the surveillance data, we were able to determine that overdoses disproportionally affected specific geographic areas in Jefferson County. The practice adapted to reduce inequitable health outcomes by making concentrated efforts in these “hot spot” areas to partner with local pharmacies for free naloxone distribution. Additionally, shifting demographics in the distribution of overdoses has encouraged partnerships with community stakeholders to reach special populations affected. Stakeholders included churches, non-profits, and local officials to inform them of services offered. Partnership with a local homeless service provider assured that we were reaching a population of patients that had limited access to the technology needed to complete the online training. Socially distanced trainings occurred to meet the needs of this population and assure they have access to naloxone.

Early lessons learned have been that when we have an urgent need, we are able to mobilize quickly in response to the needs of the community. We have learned the value of internal and external partnerships when bringing the community together when there is an urgent public health need. Specifically, we’ve learned how to: form and navigate internal and external partnership quickly due to public health need, how to have an expedited public health ruling from the Board of Medical Examiners, how to promote a platform to reach an audience, and how to take and implement feedback from an external website among many other lessons. We’ve learned that we are capable of strong partnership and innovation during times of great distress. The entirety of the online naloxone training program will be sustained post-pandemic. Aspects of the program that will be incorporated into future programs post-pandemic will be the continued use of online training for service delivery. By not relying on in-person training, this program expands the reach of our small team. Even though we had a process for naloxone delivery, we had a limited number of individuals we could reach. We are able to exponentially reach the county and state with our new program. The meaningful public health impact of the practice is to reduce overdoses deaths by increasing accessibility to naloxone.