South Park Library, Seattle: Opioid Overdose Education
University of Washington School of Nursing
Partnerships in Community Health (Autumn Quarter 2017)
Instructors: Hilary Jauregui & Eleanor Marsh
Students (Co-authors): Rachelle Eckert, Ramona Emerson, & Matt O’Hare
Abstract
Recent major news outlet attention has been drawn toward an important prevailing public health epidemic: opioid addiction. Over the course of 10 weeks, our project team partnered with the community of South Park, in Seattle, Washington. During this time-frame, implementation of the nursing process was combined with community and public health principles. Through capacity building, our group assisted our community partner in learning the about opioid reversal administration programs and the development an informational pamphlet was created specifically for community member education about opioid overdose identification and prevention promotion. Numerous organizations across the Nation have developed resources to help communities gain access to opioid reversal medications by developing outreach products, educational pamphlets, videos, and information on how to obtain a reversal kit. Effective overdose education involves a multi-modal approach that amplifies effort toward combating the current national opioid epidemic.
Introduction
As of October 26th, 2017, the current federal administration has declared the opioid epidemic to be a public health emergency (Merica, 2017). Public libraries are a common location for opioid use across the country due to being a “frequent community resource congregation point” (Murphy, 2012). Naloxone, more commonly known by the brand name
Narcan, is an opioid-antagonist medication that has been safely used to reverse opioid overdose for decades (Castillo, 2014). As a large-scale life preservation measure, multiple metropolitan library systems across the United States have implemented opioid reversal administration programs. This program empowers individuals to deliver life-saving medication to overdose victims (Klimas et al., 2015).
Our team partnered with supervisory librarian Lupine Miller to facilitate capacity building regarding opioid reversal programs and opioid overdose education for South Park. Our partner group set out to identify the commonalities within the community members of South
Park, Seattle, amongst other demographic and geographical locations of interest that currently possess this type of program. Additionally, our team explored existing evidence of library staff using naloxone and were inspired by the report titled The Opioid Epidemic is so Bad That
Librarians Are Learning How to Treat Overdoses (Simon, 2017).
Assessment
The following factors were central to our project development: conducting windshield assessment(s); integrating Quad Council Competencies for BSN Public Health Nursing; and applying Community Based Participatory Research (CBPR) principles.
Our windshield assessment did not reveal any overt indications of drug use within in the community. We did observe several items that potentially indicate a negative effect toward numerous social determinants of health including: no easy access to grocery store(s), abandoned residential housing with boarded up windows, multiple residential security home placards, steel window barricades, multiple graffiti locations (see Figures 1 & 2), and evidence of infrastructure in disrepair
(e.g. fractured sidewalks and unimproved gravel roads). We also noted positive indicators for social determinants of health in the community including: multiple community health centers, centers for immigration Figure 1 (28SEP17 services, and evidence of well-maintained community gathering places Windshield Assessment)
(e.g. the South Park Community Center and South Park Library).
Our group reviewed key statistics about opioid prevalence, incidence, and its associated reporting. There were a record number of drug-related deaths in King
County in 2016 (Young, 2017). Of those 332 deaths, two-thirds were caused by opioids (Bantam-Green, et al., 2017). From 2012-2015 heroin was the most common drug detected in overdose deaths in people under the age of 30 in King County (Alcohol and Drug Abuse Institute, Figure 2 (28SEP17 Windshield Assessment) 2017). According to public records obtained from the Seattle Fire
Department, in 2013 and 2014 (most recent data available) there were three opioid-related deaths in South Park, Seattle (Appendix E).
According to our interview with Lupine Miller, there was one non-fatal overdose inside the South Park library in 2017. These may not seem like huge numbers, but it's important to remember that many overdoses are not fatal and many go unreported. This may be especially true in a community, like South Park, with a large population of people who have not yet gained citizenship. Figure 3 indicates approximately 21.6% of the population residing in South Park, Seattle do not possess current citizenship (Statistical
Atlas, 2015). Our group believes that fear of serious repercussion, such as deportation, implication, and potential fine and/or confinement are some potential reasons that the community inhabitants of South Park, Figure 3 (Citizenship & National Origin, Statistical Atlas, 2015)) Seattle may under-report or be hesitant to report overdose events.
Another key social determinant of health is education level. Utilizing statisticalatlas.com
(See Figure 4), we identified that South Park’s high school diploma completion rate was less than 22.5 percent of that of the greater Seattle area (Statistical Atlas, 2015). The findings via
Shankar and colleagues’ study in 2013 indicates that
“educational attainment is increasingly being recognized as an important social determinant of health,” and further demonstrates that members of the Figure 4 (Educational Attainment, Statistical community are at increased risk of preventable physical Atlas, 2015) and mental health ailments (Shankar et al., 2013).
Guided by the community based principle, involve systems development using a cyclical and iterative process, we nested this with the first domain of the Entry-level BSN Quad Council
Competencies for Public Health Nurses, analytic & assessment skills, by seeking to identify metropolitan locations that had developed a successful opioid reversal medication administration program (Israel et al., 2005). This information was shared with our community partner and furthered our understanding for how key of a role collaboration plays, along with the importance of accurate statistical analysis interpretation. Planning
“Promoting a long-term process and commitment to sustainability,” was a CBPR principle our group embodied during the planning process (Israel et al., 2005). Understanding the long-term relationship possessed between the community of South Park, Seattle, and the
University of Washington, we are confident that follow-on groups of students will carry through this commitment. For our project, this principle signifies that strengthening opioid overdose education and circulation of prevention strategies embody principles established by Israel and colleagues to achieve the community partner’s intent.
The community partner’s initial interest entailed capacity building and identifying information about opioid overdose programs. Armed with the community’s intent, our mindset was geared toward influencing institutional policy through second, or third, order-effect to impact the South Park community. Through statistics research and conduction of key interviews, our team effectively set the stage to plan for our community partner’s vision in mind: preventing opioid-related deaths at the South Park branch of the Seattle Public Library.
With the community as partner, another objective was developed: develop an informational pamphlet about overdose identification and opioid reversal education. This objective reinforces the CBPR principle, “focusing on the local relevance of public health problems,” (Israel et al., 2005). Once this product was generated, we intended to incorporate the
CBPR principle of, “disseminating results to all partners and involve them in the dissemination process,” (Israel, et al., 2005). Objectives toward our goal of promoting opioid reversal medication administration and developing a community education pamphlet were refined, in content, as we adapted our effort in a non-linear fashion as understanding developed. The CBPR principle previously stated would be achieved by attending at least one community meeting, interviewing outside agencies, and collecting information to create an educational flier.
Implementation
In order to better comprehend opioid reversal medication administration programs and develop an appropriate informational pamphlet, our team committed to conducting key interviews to gain insight from library personnel around the country. This was completed using the following CBPR principle in mind: “disseminate findings and knowledge gained to the broader community and involve all partners in the dissemination process,” (Israel et al.,
2005). Additional research was also conducted to include objective studies focusing on lay- person opioid reversal administration.
Chera Kowalski heads the opioid reversal program as a librarian at the McPherson
Square Branch of the Philadelphia Library system. The most pertinent information gained from her interview revealed the safety of opioid reversal administration(s) at her location, which corresponded with the scholarly journal information, represented in Wheeler and associates’ study, regarding the safe administration of opioid reversal medications by hundreds of thousands of lay-persons (Wheeler et al., 2015). Per her testimony, only one individual whom was revived using an opioid reversal medication became hostile. This report additionally links well with a study conducted by Walley and colleagues, indicating that 3%-5% percent of people who were revived with Narcan become combative (Walley, 2015).
Another key interview was conducted at the Seattle Central Library location with the
Security and Facilities Manager, Aaron Bert. Mr. Bert revealed that the probability of implementing an institutionally adopted opioid reversal program at Seattle’s public library system would likely not be immediately possible due to the lack of evidence of an emergent overdose problem. He told us there had been a handful of overdoses in the entire SPL system in the last year. Mr. Bert also iterated that the rapid response times of emergency services to many of the Seattle Public Library locations down-plays the need for full-scale institutional adoption.
Evaluation
Throughout our project, our group felt we would be able to better facilitate community desire for education through dissemination of information gained. On November 14th, 2017, a representative for our team spoke at the South Park Neighborhood Association (SPNA) monthly meeting. Keeping in line with CBPR principles to “foster co-learning and capacity building among all partners” (Israel, et al., 2005), our team member shared the focus of our research, our progress, and collaborative ideas with Lupine Miller of creating an educational pamphlet.
A process evaluation identified that we received positive reactions, as well as statements of interest, for community based training from community attendees of the SPNA meeting. Additional curiosity was expressed by community members about how to identify overdose symptoms, along with what methods of education exist. Future process evaluation should entail a better designed method for determining how future effort should be allocated, as well as understanding the community’s desire for the location, duration, and frequency of opioid related material presentation.
Overall, our research process was successful at identifying and synthesizing relevant information required to satisfy our goal and associated objectives as we reviewed our outcome evaluation. Presentation of information to community members allowed for an additional evaluation of the community’s desire to address a deficit in knowledge. This opportunity also identified community interest in additional development of educational materials, instruction, and potential for widespread information dissemination. Our project’s community partner, Lupine Miller, was present at the SPNA meeting and expressed that she was pleased with the progress of our collective effort and supported the development of our educational pamphlet. She also understood the program’s content complexity and appreciated our investigative efforts.
Recommendations
Our group combined effort with our community partner toward the inner workings of an opioid reversal administration program and developed an informational pamphlet for future use. With these objectives in mind, future community member education efforts bare the potential to inspire neighborhood members to identify overdose symptoms and react accordingly. Additional work that is conducted across the community spectrum to promote educational attainment of opioid overdose awareness and reversal medications will arm participants with life-saving power and we recommend future action be taken toward this effort.
As a publicly funded entity and an organization that promotes intellectual freedom, we suggest that the library system circulate information regarding the availability of opioid reversal medications and the leniency of Washington state laws regarding its administration. We recommend the development of additional informational pamphlets that identify the physical address locations for where take-home opioid reversal kits can be procured and their relative cost. Finally, identification of appropriate educational information should be sought about harm reduction awareness and publicly funded entities that provide instruction to community members about substance addiction treatment services and how they can be accessed.
Conclusion
The relative participation of our group is miniscule, within the context of operating in, around, and for South Park, and though we did not directly conduct an official study, these adopted guidelines significantly enhanced our appreciation of the community health nursing process and drove the development of our project. As mentioned earlier, the study by Wheeler and colleagues reveals that “over 26,000 have been saved by lay-person naloxone administration,” and, furthermore, educational promotion accompanied these individual’s advocacy for life (Wheeler, et al., 2015). The same initiatives and training pathways that constitute Wheeler and colleagues’ conclusions should be made available nation-wide. Even though the opioid epidemic devastates lives, education and public awareness are initial steps that can begin to repair the damages.
Appendix A: Legislation
RCW 4.24.300
This link provides WA state law regarding immunity from liability for certain types of
medical care.
RCW 69.50.315
This link provides WA state law regarding medical assistance for drug-related overdose
and the clarification that there is no prosecution for possession of opioid reversal
medications.
Engrossed Substitute House Bill 1671
This link provides access to the bill that substantiates how increasing access to opioid
antagonists will prevent opioid-related deaths.
Appendix B: Key Opioid Reversal Medication Administration Program References
Surgeon General’s 2016 Report: Facing Addiction in America
This link provides laypersons and health professionals access to review the latest
evidence based breath-through studies about addiction.
King County: Heroin and Prescription Opiate Addiction Task Force
This link provides evidence of current King County Task Force development to combat
the emerging issue and serves as a resource for future use and/or consideration.
Start a Naloxone Program
This link provides specific information about how individuals, institutions, or entities can
develop an opioid reversal medication administration program. givenaloxone.org
This link provides specific education in an online format for multiple individuals.
Manual for Nurse Practitioners: Using a Computer-Based Naloxone Training Module To Prepare
Community Members for Opioid-Associated Overdose
These links provide online education products that are geared toward community action
program establishment and protocol refinement.
Opiate / Opioid Overdose: Frequently Asked Questions Pamphlet
This link provides additional information on commonly asked questions about opiate /
opioid overdose, and briefly summarize additional information available at
stopoverdose.org and givenaloxone.org.
New York State’s Opioid Overdose Prevention Program
This link provides representation of a specific state-sponsored opioid reversal medication
program, to include principles of project vision, strategy, and enduring sustainment. Appendix C: Scholarly Sources Reviewed During Project – Not Used During Final Report
(Future Project Group Reference Continuity)
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Appendix D: South Park, Seattle, Opioid Reversal Medication Educational Pamphlet
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