(12) Implementing an Opioid Overdose Prevention Program within a Community Mental Health Clinic

Background & Introduction: Co-occurring mental illness and substance use disorder is highly prevalent in the US, affecting 21.5 million adults in the US as of 20221. Having a mental health disorder is associated with nearly a 3-fold increased risk of opioid overdose2. Implementation of opioid overdose prevention programs (OOPP) are an effective way to significantly reduce opioid overdose at the community level3. OOPPs have been implemented in various clinical settings, including primary care clinics and hospitals4. However, OOPP implementation have not yet described in mental health clinics. Montefiore Behavioral Health Clinic (MBHC) is an open-access community mental health clinic located in the Bronx, which has been affected by the highest overdose rate in New York City (NYC) at 73.6 per 100,00 residents.5 Since 2013, MBHC has provided comprehensive outpatient mental health care within the community and sees an annual volume of 60,000 visits among patients age 4 and up, most of whom are Black and Latinx and publicly insured. To address neighborhood disparities in overdose rates as well as overdose risk among patients with mental illness, MBHC sought to implement an OOPP that would increase community access to overdose education and naloxone distribution.

Methods: The OOPP implementation process involved four key phases at MBHC: (1) establishing a steering committee within the mental health clinic, (2) partnering with the city health department on naloxone sourcing and reporting, (3) training clinical staff in opioid overdose education and naloxone distribution, and (4) customizing referral workflows for patients with co-occurring conditions. The OOPP steering committee consisted of the clinic’s medical director, administrative director, and an addiction psychiatrist champion who focused on developing policies and procedures and engaging stakeholders. The steering committee procured free intranasal naloxone and accessed technical assistance from the city health department, including multilingual patient educational handouts, training videos, and standardized forms for tracking and reporting on naloxone distribution. All clinical providers and staff were required to complete naloxone dispenser trainings offered thru the city health department. Overdose education and naloxone distribution was offered during the intake process for all new patients seeking mental health care at MBHC on an opt-out basis. Additionally, all interested patients and family members were eligible for internal referrals from providers and staff. Patients were directed to watch an 8-minute overdose response training video at the clinic before receiving a naloxone kit supplied with two doses of naloxone nasal spray.

Results: From fall 2019 to summer 2024, the steering committee met bi-monthly to develop and refine OOPP policy and workflow. The number of naloxone kits distributed to patients and those remaining in clinic inventory were tracked and reported back to the city public health department monthly. The number of patients who received overdose response training, as well as the number of clinic providers and staff who completed naloxone dispenser training, were also tracked and communicated back to the city public health department via monthly summary reports. Over the five-year implementation period, MBHC has distributed 2,010 naloxone kits and provided overdose education to 918 individuals who accessed mental health services in the community. A total of 33 clinical providers and staff are currently trained to dispense naloxone, including psychiatrists, psychiatric nurse practitioners, nurses, social workers, psychologists and clerical support staff.

Conclusion & Discussion: The distribution of over 2,000 naloxone kits at MBHC between 2019-2023 demonstrates both the feasibility and effectiveness of OOPP implementation within mental health clinics. MBHC is a large open-access mental health clinic licensed under NY Office of Mental Health. Because OOPP implementation has focused largely on healthcare settings licensed under the NY Department of Health, separate licensing bodies and regulations may have limited OOPP expansion to mental health clinics where patients with co-occurring disorders access care. Based on the most recent public listing of OOPPs in NYC, MBHC is the only OOPP operating within a mental health clinic in the Bronx. Though data collection was limited to monthly counts of patients trained and naloxone kits distributed, future program evaluation will be refined to better characterize the demographic and clinical characteristics of naloxone recipients. Future workflows will be expanded to include referrals to syringe service programs, mutual aid groups, and substance use treatment programs, as well as on-site initiation of buprenorphine and connection to methadone treatment. Overall, our pilot data demonstrates that harm reduction services can be integrated into an outpatient mental health clinic to better address co-occurring substance use and overdose risk among individuals being treated for primary psychiatric disorders.

References: 1. 2022 National Survey on Drug Use and Health (NSDUH) Releases. Samhsa.gov. Published 2022. https://www.samhsa.gov/data/release/2022-national-survey-drug-use-and-health-nsduh-releases#annual-national-report
2. Van Draanen J, Tsang C, Mitra S, et al. Mental disorder and opioid overdose: a systematic review. Soc Psychiatry Psychiatr Epidemiol. 2022;57(4):647-671. doi:10.1007/s00127-021-02199-2
3. Walley AY, Xuan Z, Hackman HH, et al. Opioid overdose rates and implementation of overdose education and nasal naloxone distribution in Massachusetts: interrupted time series analysis. BMJ. 2013;346:f174. Published 2013 Jan 30. doi:10.1136/bmj.f174
4. Office of Drug User Health AIDS Institute New York State Department of Health. Putting the Pieces Together: A Guide for New York State’s Registered Opioid Overdose Prevention Programs.; 2019. https://www.health.ny.gov/diseases/aids/general/opioid_overdose_prevention/docs/policies_and_procedures.pdf
5. Bureau of Vital Statistics/Office of Chief Medical Examiner, New York City; Rates calculated using NYC DOHMH population estimates, modified from US Census Bureau intercensal population estimates 2000-2021, updated September 2022. Analysis by Health Department's Bureau of Alcohol and Drug Use Prevention, Care and Treatment