NEXT Harm Reduction: An Online, Mail-Based Naloxone Distribution and Harm-Reduction Program by nextdistro

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NEXT Harm Reduction: An Online, MailBased Naloxone Distribution and Harm-Reduction Program Carol Yang, BA, Jamie Favaro, MSW, and Meredith C. Meacham, PhD, MPH

Needle EXchange Technology (NEXT) Harm Reduction is an online, mail-based platform designed for sending (1) naloxone kits to people at risk for overdose and (2) sterile syringes and other equipment directly to people who otherwise cannot access safe supplies. From its inception in 2017 through the end of 2019, NEXT Harm Reduction sent naloxone kits to 3609 individuals and 1230 packages of sterile syringes and supplies and received 335 reports of overdose reversals using naloxone provided by NEXT Harm Reduction and its aﬃliates. (Am J Public Health. Published online ahead of print February 18, 2021: e1–e5.

overdose, and NEXT Distro, which mails

implementation, impact, and public

sterile syringes and other drug use

PERSON

health signiﬁcance of Needle EXchange

equipment, as well as naloxone, directly

NEXT targets people who use drugs and

Technology (NEXT) Harm Reduction and

to people who otherwise cannot access

their loved ones who are not able to

outline challenges and opportunities to

safe supplies. Both programs are ac-

access naloxone or sterile syringes and

inform other organizations who may be

cessible via https://nextdistro.org.

other resources for safer drug use in

interested in expanding or integrating

(Before October 2020, NEXT Nalox-

their local communities.

online, mail-based harm-reduction ser-

one’s Web page was https://www.

vices in their communities.

naloxoneforall.org, which now redirects

PURPOSE

to https://nextdistro.org.)

INTERVENTION

Many people in the United States still

PLACE AND TIME

have little or no access to naloxone (brand name: Narcan), the Food and

NEXT Harm Reduction is an online, mailbased platform designed to reduce

Through a network of harm-reduction

Drug Administration–approved medica-

opioid overdose deaths; prevent

agencies and health departments, NEXT

tion that prevents opioid overdose death

injection-related transmission of condi-

serves participants in all 50 states;

by reversing opioid-induced respiratory

tions including HIV, hepatitis C, and soft

Washington, District of Columbia; and

depression.2 Furthermore, people who

tissue bacterial infections; and improve

Puerto Rico. It is based in New York City,

use drugs still face physical, legal, and

the lives of people who use drugs and

where it is a registered New York State

societal barriers to supplies for safer drug

Published online ahead of print February 18, 2021

n this article, we describe the purpose,

AJPH

https://doi.org/10.2105/AJPH.2020.306124)

their loved ones. It is a 501(c)(3) orga-

Opioid Overdose Prevention Program

use. Stigma against and criminalization of

nization originally sponsored by the

and Syringe Exchange Program. NEXT

drug use continues to prevent many

Harm Reduction Coalition.

Distro began services in February 2018

people from accessing lifesaving re-

NEXT Harm Reduction runs two pro-

and NEXT Naloxone began services in No-

sources even when they are available.3 As

grams: NEXT Naloxone, which provides

vember 2018. It was inspired by the work of

smartphone and Internet use becomes

online overdose prevention education

Tracey Helton and conversations at the

more accessible, people are increasingly

and mail-delivered naloxone kits to

2016 National Harm Reduction Coalition

using the Internet to obtain health infor-

the loved ones of people at risk for

Conference in San Diego, California.

mation, medications, and supplies.4

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Yang et al.

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IMPLEMENTATION

TABLE 1—

Demographics and Overdose Experiences of NEXT Naloxone Requesters: United States and Puerto Rico: November 2018–December 2019

Program participants typically learn about NEXT Naloxone through social media (48%) and personal connections (23%; Table 1). This information was not

Age, y

systematically collected from NEXT Dis-

< 26

tro participants to reduce program and

26–45

2352 (60)

participant burden.

46–65

677 (17)

Along with mailing supplies, NEXT programs include a handwritten note

> 65

43 (1)

Gender identitya Male

1334 (34)

package. Web pages and other written

Female

2390 (61)

materials are oﬀered in English and

Gender nonconforming or nonbinary

referrals to other support services in their area, including buprenorphine Published online ahead of print February 18, 2021

848 (22)

and informational materials in each

Spanish. Participants can also request

AJPH

New Requests, No. (%)

providers, harm reduction–oriented physicians, and mental health services. Postage for NEXT is paid for through grant funding and donations. NEXT sends packages through the US Postal Service priority mail, which typically take two to four days to arrive to participants.

Transgender

141 (4) 43 (1)

Racial/ethnic identitya White or Caucasian

3448 (88)

Black or African American

119 (3)

Hispanic or Latinx

278 (7)

Asian

104 (3)

American Indian or Alaska Native

67 (2)

Native Hawaiian or Paciﬁc Islander

24 (1)

Overdose experience in past year Witnessed

2162 (55)

Has overdosed

344 (9) b

Region: Northeast

NEXT Naloxone

Total requests

771 (20)

Filled (% of total)

672 (87)

Diverted to local programs (% of total)

53 (7)

Region: Midwestc

Upon arriving on the NEXT Naloxone

Total requests

1132 (29)

Web page, participants select which

Filled (% of total)

1046 (92)

state they reside in and are directed to a

Diverted to local programs (% of total)

state-speciﬁc resource page. If they are

34 (3)

Region: South and Puerto Rico

unable to access resources in their state,

Total requests

1349 (34)

participants can watch a training video

Filled (% of total)

1262 (94)

on overdose recognition and naloxone use, then ﬁll out a secure online form to

Diverted to local programs (% of total)

31 (2)

Region: Weste

request naloxone via mail. In states

Total requests

674 (17)

where NEXT Naloxone has a partner

Filled (% of total)

629 (93)

aﬃliate (typically a local harm-reduction

Diverted to local programs (% of total)

organization that already distributes

31 (5) Continued

naloxone within their state), NEXT forwards the request to the aﬃliate to coordinate and fulﬁll the delivery. Part-

expected turnaround times for requests

intranasal Narcan-brand naloxone.

ner aﬃliates have signed memoranda of

to be mailed out.

The type and amount of naloxone sent

understanding with NEXT, which include terms of participant conﬁdentiality and e2

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NEXT oﬀers both intramuscular naloxone vials with syringes and

to each participant depends on their request, level of overdose risk, state of

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TABLE 1—

residence, and available inventory Continued

(typically two to four doses, or more New Requests, No. (%)

How requester heard about NEXT Naloxone Social media

for individuals at higher risk for overdose).

1889 (48)

Personal connection

910 (23)

Online search or Web site

680 (17)

Recovery or support group

178 (5)

NEXT Distro To access NEXT Distro services, people connect via the program Web site

Note. The sample size was 3926.

(https://nextdistro.org) or reach out di-

rectly via e-mail, text message, or social media (Instagram: @nextdistro; Reddit: u/nextdistro). NEXT Distro then sends participants a link to the enrollment request form. Depending on what participants request, packages mailed to them contain supplies typically available at in-person harm-reduction programs: packs of syringes available in multiple and cotton, and safer smoking, safer sex, and wound care supplies.

TABLE 2—

Naloxone Use Reports to NEXT Harm Reduction: United States and Puerto Rico, November 2018–December 2019 a

Naloxone Use Reports, No. (%)

EVALUATION From November 2018 through December 2019, NEXT Naloxone received 3926 new requests via https://www.

Did the person who overdosed survive? Yes

335 (95)

naloxoneforall.org (Table 1). Of these,

9 (3)

3609 (92%) were ﬁlled by NEXT Nalox-

Not sure

9 (3)

one (1812 directly, 1797 via aﬃliates),

Relationship of person who reported overdose to person who overdosed Friend or acquaintance Family member or partner Patient or client

149 (4%) were diverted to local programs, and 168 (4%) were undeliver-

161 (46)

able. From February 2018 to

84 (24)

December 2019, NEXT Distro sent

6 (2)

Stranger

72 (20)

Unknown or prefer not to answer

30 (8)

1230 packages containing syringes and other supplies. Each naloxone kit and package in-

Location of overdose Home or apartment

cludes reminders with the link to an

238 (67)

Public - inside

21 (6)

online form for participants to report

Public - outside

58 (16)

back to the program if they have used

4 (1)

the naloxone from NEXT to respond to

32 (9)

an overdose and whether the reversal

Shelter or supportive housing Other or unknown

Published online ahead of print February 18, 2021

sizes, hazardous material bins, cookers

AJPH

People could select more than one response option for racial/ethnic and gender identity. b Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont. c Midwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin. d South and Puerto Rico: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virginia, and West Virginia. e West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming. f Based on free text responses to the question “How did you hear about NEXT Naloxone?”; response categories are not mutually exclusive (e.g., “Facebook friend” would count as social media and personal connection).

attempt of the overdose was suc-

Region Northeastb c

Midwest

cessful. NEXT also e-mails periodic

62 (18)

reminders to all participants who have

63 (18) Continued

received kits to report back to the

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TABLE 2—

communities of color at higher risk of Continued

experiencing or witnessing an overdose.7 Naloxone Use Reports,a No. (%)

South and Puerto Rico

188 (53)

Weste Demographics of person who overdosed

While NEXT has not received reports

Age, y

of adverse eﬀects or unintended con-

< 26

91 (26)

26–45

216 (61)

46–65

21 (6)

> 65

0 (0)

Unknown

25 (7)

Gender identity

Published online ahead of print February 18, 2021

ADVERSE EFFECTS

40 (11)

Male

227 (64)

Female

100 (28)

Gender nonconforming or nonbinary

2 (1)

Transgender

3 (1)

Not reported

21 (6)

sequences, a primary concern is the conﬁdentiality of participant information related to admission of substance use or interception of packages. To guard against this, NEXT does not connect participant enrollment data (i.e., names, addresses) with potentially sensitive substance use information. The processes of enrolling and requesting supplies are separated and connected through a participant-

Racial/ethnic Identity White or Caucasian

262 (74)

chosen “handle.” Furthermore, NEXT

Black or African American

32 (9)

encourages participants to use

Hispanic or Latinx

21 (6)

encrypted messaging applications to

Asian

5 (1)

communicate with the program. Nev-

American Indian or Alaska Native

8 (2)

ertheless, many program participants

Native Hawaiian or Paciﬁc Islander

0 (0)

report more concern about scarcity of syringes and naloxone than about po-

Previously experienced overdose 188 (53)

No or not sure

165 (47)

AJPH

Yes

tential privacy risks.

SUSTAINABILITY

Note. The sample size was 353. a

Some people reported multiple naloxone use reports. Northeast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont. c Midwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin. d South and Puerto Rico: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virginia, and West Virginia. e West: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming. b

The sustainability of NEXT is largely driven by aﬃliate partnerships based in communities where participants are requesting supplies. Aﬃliate partners are able to tailor delivery of supplies to local circumstances and can develop more direct supportive relationships with participants.

program if they use their naloxone and

A central limitation and concern of

One concern of expansion via govern-

may need reﬁlls. During this period,

NEXT is that it is primarily reaching in-

ment partnerships is whether formaliza-

there were 353 participant reports of

dividuals who have a dependable mail-

tion will create barriers that prevent

naloxone used to respond to an over-

ing address and reliable access to the

participants from electing to share their

dose, of which 335 (95%) were successful

Internet, creating barriers for participants

information. Government partners

in reviving the person overdosing

who are unhoused, unstably housed, or

should be aware of this concern and

(Table 2). This is likely an underestimate as

without Internet access.6 Furthermore, as

ensure that identifying participant infor-

lay person overdose reversals are often

program participant demographic data

mation is not used or distributed for any

underreported.5

show, NEXT has had limited reach in

purpose beyond provision of supplies.

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PUBLIC HEALTH SIGNIFICANCE

Note. The content is solely the responsibility of the authors and does not necessarily represent the oﬃcial views of the National Institutes of Health.

In the context of the opioid overdose

CONFLICTS OF INTEREST

crisis and ongoing HIV and hepatitis C

The authors have no conﬂicts of interest to declare.

epidemics, as well as active political opposition to local syringe access programs in many parts of the country, NEXT Harm Reduction provides an innovative platform for people who use drugs and others in their community to connect with low-barrier access to information, support, and life-saving medication and supplies. ABOUT THE AUTHORS

Correspondence should be sent to Meredith Meacham, 401 Parnassus Ave, San Francisco, CA 94143 (e-mail: meredith.meacham@ucsf.edu). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link.

PUBLICATION INFORMATION Full Citation: Yang C, Favaro J, Meacham MC. NEXT harm reduction: an online, mail-based naloxone distribution and harm-reduction program. Am J Public Health. Published online ahead of print February 18, 2021: e1–e5. Acceptance Date: December 13, 2020. DOI: https://doi.org/10.2105/AJPH.2020.306124

CONTRIBUTORS C. Yang is the former program director for NEXT Harm Reduction and contributed to the writing and editing of the article. J. Favaro is the founder and executive director of NEXT Harm Reduction and contributed to the editing of the article. M. Meacham performed the data analyses and contributed to the writing and editing of the article.

REFERENCES 1. Larney S, Peacock A, Leung J, et al. Global, regional, and country-level coverage of interventions to prevent and manage HIV and hepatitis C among people who inject drugs: a systematic review. Lancet Glob Health. 2017;5(12):e1208–e1220. https://doi. org/10.1016/S2214-109X(17)30373-X 2. Fairbairn N, Coﬃn PO, Walley AY. Naloxone for heroin, prescription opioid, and illicitly made fentanyl overdoses: challenges and innovations responding to a dynamic epidemic. Int J Drug Policy. 2017;46:172–179. https://doi.org/10.1016/j.drugpo. 2017.06.005

Published online ahead of print February 18, 2021

CORRESPONDENCE

Institutional review board approval was not required for this study because the data were collected for program evaluation purposes and presented in aggregate.

AJPH

Carol Yang and Jamie Favaro are with NEXT Harm Reduction, New York, NY. Meredith Meacham is with the Department of Psychiatry and Behavioral Sciences at the University of California San Francisco.

HUMAN PARTICIPANT PROTECTION

3. Tsai AC, Kiang MV, Barnett ML, et al. Stigma as a fundamental hindrance to the United States opioid overdose crisis response. PLoS Med. 2019;16(11): e1002969. https://doi.org/10.1371/journal.pmed. 1002969 4. Greenberg-Worisek AJ, Kurani S, Finney Rutten LJ, Blake KD, Moser RP, Hesse BW. Tracking Healthy People 2020 Internet, broadband, and mobile device access goals: an update using data from the Health Information National Trends Survey. J Med Internet Res. 2019;21(6):e13300. https://doi.org/10. 2196/13300 5. Wheeler E, Jones TS, Gilbert MK, Davidson PJ. Opioid overdose prevention programs providing naloxone to laypersons—United States, 2014. MMWR Morb Mortal Wkly Rep. 2015;64(23):631–635. 6. van Draanen J, Tsang C, Mitra S, Karamouzian M, Richardson L. Socioeconomic marginalization and opioid-related overdose: a systematic review. Drug Alcohol Depend. 2020;214:108127. https://doi.org/ 10.1016/j.drugalcdep.2020.108127 7. Lippold KM, Jones CM, Olsen EO, Giroir BP. Racial/ ethnic and age group diﬀerences in opioid and synthetic opioid–involved overdose deaths among adults aged ≥18 years in metropolitan areas— United States, 2015–2017. MMWR Morb Mortal Wkly Rep. 2019;68(43):967–973. https://doi.org/10. 15585/mmwr.mm6843a3

ACKNOWLEDGMENTS Manuscript development was supported by National Institutes of Health grant K01DA046697. The authors would like to acknowledge Tracey Helton for her pioneering work in mail-based naloxone distribution, Dan Coello for their data management assistance, and advisors and aﬃliates of NEXT Harm Reduction.

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