State prevention leaders in South Carolina joined forces with local police departments to create an effective naloxone training, distribution, and monitoring program.
About the Collaboration
On June 3, 2015, then Governor Nikki Haley signed the South Carolina Overdose Prevention Act into law, increasing medical professionals' access to the anti-overdose drug naloxone and authorizing first responders, including firefighters and police officers, to carry and administer it.1,2 The need to expand the safe use of this life-saving medication was urgent. In 2015, 468 people in South Carolina had died from opioid-related overdoses, up from 453 deaths the previous year.3
Police involvement in administering naloxone was critical, as police officers were frequently first on the scene of many overdoses. "Many of our counties are very rural. It takes anywhere from six to eight minutes for an ambulance to respond to a 911 call, whereas law enforcement typically responds in four minutes or less," says Michelle Nienhius, Prevention Manager for the South Carolina Department of Alcohol and Other Drug Abuse Services (DAODAS). "When someone overdoses on heroin or other opioid drugs, minutes can mean the difference between life and death."
But the new state law presented challenges to local law enforcement. "Many of them thought that it was not their place, that administering naloxone was for [emergency medical services] to provide," says Nienhius.
To prepare law enforcement for their new role, DAODAS worked with the state Department of Health and Environmental Control's Bureau of Emergency Medical Services to create a pilot overdose prevention/naloxone training and monitoring program. "We were fortunate to have a forward-thinking partner who had experience training EMTs to use naloxone," Nienhius says. With additional input from the state’s Fifth Circuit Solicitor’s Office, and naloxone products donated by two pharmaceutical companies, the team created the Law Enforcement Officer Naloxone (LEON) program—a comprehensive training and online reporting system.4
In January 2016, the state began pilot-testing LEON with six county law enforcement agencies. The program was highly successful, with all participating officers passing the mandatory post-training exam. With funding from SAMHSA's Grants to Prevent Prescription Drug/Opioid Overdose-Related Deaths (PDO), DAODAS expanded the program to 15 high-need counties, and eventually to 65 law enforcement agencies across South Carolina’s 46 counties. Today, law enforcement officers routinely administer naloxone—saving lives and giving people with substance use disorders another chance at recovery.
Nienhius attributes the success of the pilot to the close attention DAODAS and partners paid to ensuring “fit.” The state worked closely with county sheriffs and chiefs of police, taking time to learn about law enforcement culture and build relationships. These efforts helped to improve buy-in and ensure that the program was culturally competent. "We learned that cultural competency isn’t just about working with a particular population," she says. "It also means understanding the culture of the partner agencies we're working with."
Elements of Success
Respect the Chain of Command
One of the first things that Nienhius learned about police culture was that it was deeply rooted in hierarchy and respect for authority. "A street officer is not going to do something that his or her lieutenant or sergeant or corporal doesn't support," she says. "No one is going to go rogue." So before she and her partners could make progress, they needed to get buy-in from the top. "We went to [police department leaders] first to have conversations about their comfort level with carrying and using naloxone," she says. "We had open conversations about their fears and concerns." These initial conversations helped reassure law enforcement leaders that the program was designed to keep their officers and the public safe.
Address Liability Issues
Law enforcement officials also wanted to know exactly what the new South Carolina Overdose Prevention Act meant—and what protection it offered officers who would be administering the medication. To provide this information, Nienhius enlisted the help of a government attorney to explain the law and address the department’s concerns. "We had one of our local solicitors who was involved in writing the legislation come in and answer questions," she says. "This provided the sheriffs and chiefs with the information they needed to feel comfortable about creating standard operating procedures within their departments, and to have law enforcement officers know that when they administered the medication, they were administering it properly." The state also established memoranda of agreement with each participating law enforcement agency that detailed procedures for legally carrying and administering naloxone.
Tailor Training to Law Enforcement
Police face the unknown every day. That's why cops need to "do things by the book." They operate within the confines of the law, with the backbone of policies and procedures in place. It was thus important that the LEON training hinge on the policies and procedures that would guide naloxone administration and reporting, and provide detailed instructions for carrying out these activities. Adapted from content included in the SAMHSA Opioid Overdose Prevention Toolkit, the two-hour training included video of actual overdose interventions by law enforcement officers, opportunities for role play, question-and-answer sessions, and hands-on training in using the Narcan® medical device. Ultimately, police felt more confident in their new role knowing they were participating in a training that reflected an understanding of their daily experience and that was customized to meet their unique concerns.
Rely on Peer-to-Peer Training
Nienhius and partners relied on police officers, primarily those who also worked as paramedics, to deliver many of the LEON training modules. "When [law enforcement officers] receive the message from their peers, it helps reduce the stigma around talking about addiction, and puts issues in terminology that peers will understand and relate to,” says Nienhius. “Law enforcement officers can then feel free to ask questions and confident about the information they are receiving." Many of these recruited officers also served as program champions, helping to obtain the buy-in of officers who were initially wary of their new responsibilities.
Develop a User-Friendly Monitoring System
In addition to developing a strong training, the state worked with designated pharmacies to create a secure, HIPPA-compliant system to track and monitor the distribution of naloxone to police officers. It wasn't just good public health practice—it was the law. To create the system, the state's Department of Health and Environmental Control worked with the University of North Carolina at Chapel Hill to develop an online portal system. The system tracks how many doses of naloxone each officer receives and how each dose is administered, and ensures that officers who have not used their naloxone are not carrying expired doses of the drug. The portal also enabled law enforcement to capture data and information about patients and their needs, as well as problem addresses and neighborhoods (that is, where naloxone is administered more frequently). "This helps law enforcement see where additional measures may need to be taken in problem locations," Nienhius says.
According to initial evaluation findings, the LEON program “has led to a number of successes that can be considered 'saves.'"5 As of November 2017, more than 3,700 law enforcement officers have been trained across 102 agencies, resulting in 127 lives saved so far across the state.6 As the program continues to roll out across the state, more and more law enforcement officers report feeling comfortable and confident using this medication.
With support from SAMHSA’s State Targeted Response to the Opioid Crisis Grants (Opioid STR), DAODAS and partners will continue expanding the naloxone program to additional law enforcement agencies and other first responders across the state, in both high-population areas and rural communities. "Our five-year plan is to provide access to naloxone in all our communities and for all agencies that touch people, such as our highway patrolmen, our [Department of Natural Resources] officers, and our firefighters," she says. "Each agency operates differently, and it will take time. But we do have a vision."
With the recent expansion of the South Carolina Overdose Prevention Act to expand naloxone access to people with opioid prescriptions, Nienhius sees potential for more widespread training. She hopes to build on what her department has learned from LEON to prepare patients and caregivers in the state’s drug treatment system to use naloxone. "We want to make sure that if they are in a situation, that they have the knowledge and skills to provide that lifesaving dosage of naloxone themselves."
SAMHSA is working with its federal partners and state and local law enforcement to expand the safe administration of naloxone by first responders. State and local laws vary permitting or restricting naloxone use by certain types of first responders. For more information, visit SAMHSA's Naloxone webpage.
For "Five Essential Steps for First Responders," see the SAMHSA Opioid Overdose Prevention Toolkit, available as a free PDF download.
For a clearinghouse of resources to support law enforcement agencies in establishing a naloxone program, see the Bureau of Justice Assistance’s Law Enforcement Naloxone Toolkit.
1. South Carolina General Assembly, 121st Session, 2015-2016. H 3083. Summary: S.C. Overdose Prevention Act. Available at http://www.scstatehouse.gov/sess121_2015-2016/bills/3083.htm
2. The Network for Public Health Law. Drug Overdose Prevention Fact Sheet. South Carolina Overdose Prevention Legislation. Retrieved April 1, 2017. Available at https://www.networkforphl.org/_asset/n7zf8x/SC-overdose-prevention.pdf
3. The Kaiser Family Foundation. State Health Facts. Prescription Opioid Overdose Deaths and Death Rate per 100,000 Population (Age-Adjusted). Retrieved June 16, 2017. Available at http://www.kff.org/other/state-indicator/prescription-opioid-overdose-de...
4. South Carolina Department of Health and Environmental Control. (May 5, 2017.) Memorandum to House Opioid Abuse Prevention Study Committee Members on DHEC’s Role with Opioid Abuse. Available at http://www.scstatehouse.gov/CommitteeInfo/HouseOpioidAbusePreventionStud...
5. South Carolina Bureau of Emergency Medical Services. An Assessment of the Impact of the South Carolina Overdose Prevention Act of 2015 (2016.) Available at https://www.nasemso.org/Meetings/Annual/documents/Assessment-of-Impact-S...
6. South Carolina Department of Alcohol and Other Drug Abuse Services. (November 2017). Opioid Factsheet: A Glance at the Impact of Opioids. Available at http://www.daodas.sc.gov/wp-content/uploads/2017/11/DAODAS-Opioid-Fact-S...