Maine's Overdose Prevention Through Intensive Outreach, Naloxone and Safety (OPTIONS) Initiative.

This article outlines the successes, barriers, and lessons learned in implementing the Overdose Prevention Through Intensive Outreach, Naloxone and Safety (OPTIONS) initiative in Maine during its first year. With leadership from the Governor's Office, the Department of Health and Human Services, and the Department of Public Safety, the Office of Behavioral Health contracted with behavioral health organizations to hire and provide supervision for 16 clinicians. These behavioral health clinicians, known as OPTIONS liaisons, were each assigned to provide services for one county in the state and were embedded within a public safety agency. A technical assistance team was also assembled to assist in guiding implementation and improving this public health and public safety partnership.

Maine is experiencing a burgeoning crisis in overdose fatalities. Drug deaths increased 33% from 2019 to 2020 and are estimated to reach an all-time high of 636 in 2021, a further increase of 23% over the prior year.1 Poor health outcomes for individuals experiencing substance use disorder (SUD) are exacerbated by both the isolation and mental health stressors of the COVID-19 pandemic2–4,5 and the lethality of nonpharmaceutical fentanyl and its analogues.6 The proportion of drug deaths involving nonpharmaceutical fentanyl in Maine has increased from 68% (n = 336) in 2019 to an estimated 77% (n = 490) in 2021.1 To improve the coordination of care and health outcomes for people who use drugs, which serves as a protective factor against overdose,7,8 the Centers for Disease Control and Prevention (CDC) recommends public health and public safety partnerships to connect risk individuals to harm-reduction and prevention services.9 Improved coordination of care across the harm-reduction, criminal justice, health care, and social support setting is also a hallmark of the Biden administration's response to the growing overdose epidemic.10 In Maine, the Overdose Prevention Through Intensive Outreach, Naloxone, and Safety (OPTIONS) initiative utilizes these partnerships to link people who use drugs and affected others to a broad spectrum of state- and community-based health, subsistence, and wellness services.

Providing OPTIONS

The OPTIONS initiative, announced in October 2020 by Governor Janet Mills, embeds behavioral health clinicians—called OPTIONS liaisons—within law enforcement agencies in each of Maine's 16 counties. At present, each county has one appointed liaison who corresponds to drug-related emergency calls alongside law enforcement partners to provide short-term counseling interventions and de-escalates behavioral health crises. Liaisons also engage in postoverdose follow-up visits alongside law enforcement, referring persons and need as well as affected others to community- and state-based services. Liaisons also work within the community to conduct proactive outreach with individuals at the highest risk of experiencing an overdose, provide overdose education and naloxone distribution (OEND) trainings, and conduct anti-stigma trainings with community members, law enforcement agencies, and clinicians. To increase public awareness regarding drug overdose, destigmatize problematic substance use, and increase community awareness of the program, a robust public health messaging campaign and Web site (knowyouroptions.me) was launched to support the liaisons.

Law enforcement agencies and their embedded OPTIONS liaisons work together to link persons who use drugs (PWUD) in their communities who have experienced a suspected overdose or who are at high risk of an overdose, with care across the broad spectrum meeting these individuals where they are at in their journey of recovery from harm reduction, treatment, health care, recovery, and social services.

Multiple synergistic touchpoints were intentionally designed within the OPTIONS liaison program to leverage vital state health initiatives to increase protective factors for PWUD against overdose. In her first executive order,11 Governor Mills implemented the expansion of Maine's Medicaid system—MaineCare. Expanded insurance coverage is an essential evidence-based intervention for addressing barriers to accessing SUD treatment, physical health care, and nonemergency transportation services for disparate populations, especially those residing in rural areas without public transportation options.12 OPTIONS liaisons urge uninsured individuals to apply for MaineCare coverage and assist them with their applications. Another leveraged initiative is a Centers for Medicare & Medicaid Services' Maternal Opioid Misuse grant the Office of MaineCare Services received in 2019. OPTIONS liaisons refer consenting pregnant and postpartum persons to the MaineMOM program to receive integrated care services for both perinatal and SUD health care needs. OPTIONS liaisons receive and distribute their leave-behind naloxone kits from the Maine Naloxone Distribution Initiative. This program began in 2019, when the state collaborated with the University of Maine and contracted public health and harm-reduction partners to develop a comprehensive naloxone distribution network. Other state programs and services that OPTIONS liaisons utilize and rely upon include ME CDC Syringe Service Programs, emergency department rapid induction of medication for opioid use disorder, emergency department embedded recovery coaches, Law Enforcement Assisted Diversion programs to place PWUD on treatment and recovery pathways, and Overdose Detection Mapping Application Program (ODMAP) for postoverdose follow-up connections and proactive community outreach.

Synergistic State initiatives leveraged by the OPTIONS programs are as follows:

Maine's Medicaid Expansion efforts for MaineCare

The MaineMOM integrated care team service model for perinatal persons struggling with opioid use

Maine Naloxone Distribution Initiative

Maine CDC Syringe Service Programs

Rapid induction of medication for opioid use disorder in emergency departments

Recovery coaches embedded in emergency departments

ODMAP implementation for postoverdose follow-up visits

Department of Public Safety–funded Law Enforcement Assisted Diversion programs to better direct individuals out of the criminal justice path and toward treatment, recovery, and harm-reduction pathways

Technical assistance (TA) for the OPTIONS initiative is provided by the Maine Medical Association Center for Quality Improvement (MMA-CQI). MMA-CQI is a neutral convener committed to transforming health and health care in Maine. MMA-CQI created a learning collaborative that provides a staffed centralized community for onboarding, orientation and training, implementation assessment, identification and direct support, quality improvement, implementing data collection, site-specific TA, monthly TA meetings, and monthly coaching calls.

Evaluation Methods and Findings

Quantitative and qualitative data are being collected and analyzed by the University of Maine on the outputs and outcomes of liaisons within their counties. Aggregate data are reported by OPTIONS liaisons monthly through an online digital survey tool created in Qualtrics. Qualitative data are also being collected by the MMA-CQI TA team to address barriers to services using a climate survey and monthly coaching calls with each of the liaisons. Feedback on performance barriers such as housing and transportation instabilities or lack of residential treatment is tracked in a risk log that focuses on 4 areas: information sharing and care coordination, treatment funding and recovery support services, access to treatment, as well as all other barriers that may arise during assistance to an individual. MMA-CQI provides a direct feedback loop to the Governor's Office of Policy Innovation and the Office of Behavioral Health to eliminate barriers and increase the continuity of care for PWUD. In the first 12 months of referrals, OPTIONS liaisons linked 149 individuals to MaineCare, referred 25 perinatal persons to the MaineMOM program, and connected 472 individuals to recovery services, 186 individuals to syringe service programs, and 150 individuals for infectious disease testing. More than 1200 individuals received overdose education from the OPTIONS liaisons across the state and handed out more than 1800 intranasal naloxone doses to individuals at high risk of responding to an overdose emergency. Liaisons also report that the community has become more involved with the program through relationship building with local coalitions, emergency departments, emergency medical services agencies, law enforcement departments, and the media campaign, which increases referrals to liaisons as well as referrals by liaisons to SUD services.

The populations being reached and referred to treatment is a population that has not previously received services within the publicly funded system. Evidencing improved access to harm-reduction, recovery support, and treatment services for an otherwise unserved set of demographics: 58% homeless/unstably housed 16% Black, Indigenous, and People of Color (BIPOC). High co-response rate in more urban areas prevents one liaison from being able to cover to more rural areas. Items such as a service car, radio, and call sign would expand reach and timeliness while reducing burden on the host law enforcement agency.

Feedback loops within the learning collaborative and data sets provided by the University of Maine validate the following training and competency needs: scene safety with co-response, stigma, and bias reduction specifically for law enforcement, overdose education and naloxone distribution, how to supervise a liaison, motivational interviewing, Maine laws, that is, good Samaritan, reporting requirements in addition to onboarding orientation.

One focus for public health messaging is on the OPTIONS program and how to use “find” it and use it. Messaging has also been used to promote recovery stories to reduce stigma and bias. Direct consumer education on the prevalence of fentanyl and how to test has been provided, as well as availability and efficacy of MOUD.

The efficacy of the OPTIONS initiative is exemplified in the 91% (n = 240) rate of individuals attending their first appointment with treatment providers. Of the 9% (n = 23) listed as unknown, liaisons were unable to make follow-up contact with their client to confirm whether appointments were attended. This rate of treatment initiation is far above national initiation rates for insured adults in need of SUD treatment services, which ranges from 26% to 46%.13,14 Although empirical studies15–17 have examined the effects of providing structural procedures to increase engagement with treatment providers, future studies should address the public health and public safety partnership of the OPTIONS initiative, which connects PWUD to a broad spectrum of health and social services and meets PWUD where they are at in their journey of use, and recovery is a novel approach to linking clients to treatment services (Figure).

Number and Percentage of Clients Referred to Community-Based Substance Use Disorder Treatment Who Did and Did Not Engage With the Provider

This figure is available in color online (www.JPHMP.com).

Discussion and Conclusion

The OPTIONS liaison program has proven to be an efficacious intervention to address the burgeoning overdose crisis in Maine. Most impressive is the ability of OPTIONS liaisons to not only refer PWUD to community-based treatment programs but also ensure their clients attend their first appointment with providers by utilizing warm handoffs and follow-up contact. OPTIONS is also an integral part of Maine's robust naloxone distribution and emergency response programs that provide harm reduction to individuals at the highest risk for opioid overdose. These efforts have increased the proportion of nonfatal overdoses in the state over the past year, with a 93% rate of reported overdoses being reversed during the first 11 months of 2021.6 Implementing county-level public health and public safety partnerships can advance fatal overdose prevention efforts using methods to improve health through data sharing, coordination, collaboration, integration, and stigma reduction.