October 2018 - June 2019
Who We Are:
The Opioid Crisis Response Fund (OCRF; www.ocrfund.org) is a start-up non-profit effort with the mission to save as many lives as possible, as quickly as possible, from opiate-related fatality.
OCRF raises money, and then prioritizes grant-making for opioid response on the principle of net present value. That is—rather than prioritizing funding on a priori preferences for particular geographies, populations, or hypotheses of change—we prioritize funding on the bases of timing, size, and probability of impact.
What We’ve Done:
OCRF deployed its first round of grants to six organizations in October of 2018. Based on the 9-month impact reports we received back from these organizations, between Oct ’18 and June ’19, OCRF funding saved 983 lives (3.6 per day) at an average cost of $135.86 per-life-saved. Our cost per-life-saved figure is based on the total expenses of OCRF (FTE compensation, fundraising, administration, etc.), not just the dollar amount of the total grant funding we have deployed.
We believe OCRF is probably achieving the highest rate of effectiveness, in terms of lives saved, of any current funding effort (government-sponsored or philanthropic) addressing the opioid overdose crisis.
If we're right about this, we also believe that OCRF’s demonstrated levels of impact can be used as hurdle rates that other opioid response funders seek to meet or exceed when evaluating their own funding opportunities.
Our Approach to Funding:
OCRF has no a priori preferences regarding the means by which impact is achieved. We are only concerned that opportunities for funding are prioritized by their unmet life-saving potential—considering not only the potential size of impact, but also the timing and probability of impact.
In this way, OCRF’s funding decisions are driven by the concept of net present value (NPV). According to NPV, it is possible for a very large opportunity for gain that is long-term and/or uncertain to be less valuable than a smaller opportunity for gain that is short-term and/or more certain.
The data do not exist to precisely quantify the “NPV” of potential lives-saved of every available opioid response. But, our belief is a triaging effort based on the concept that the value of a grant is not only driven by the possible size of the impact, but also the likely timing and probability of that impact, will absolutely enable us to save far more lives than we do now.
What We Funded, and Why:
The first opioid response strategy targeted for funding by OCRF is syringe access program (SAP)-facilitated naloxone distribution. In October 2018, we funded naloxone distribution through six SAPs operating in Indiana, Ohio, Wisconsin, Iowa, Louisiana, and Connecticut.
This funding was intended to allow grantees to provide free and unrationed naloxone supply to their clients for the following year. We targeted SAPs over other avenues for naloxone distribution because these organizations serve the population most likely to witness an overdose and be first on-hand to administer naloxone. None of the SAPs we funded had sufficient, if any, access to government- or foundation-sponsored naloxone supply funding (i.e. we did not substitute for existing funding; we provided funding for naloxone distribution that otherwise would not have occurred). We funded SAPs already engaged in naloxone distribution, but lacking sufficient funding to meet clients’ total demand for naloxone. In this way, we hoped to reach SAPs that already had the client networks and distribution operations in place to begin saving lives as soon as possible with incremental naloxone supply.
OCRF is not a harm reduction fund. We are a fund with the mission to save as many lives as possible, as quickly as possible, from opiate-related overdose. Targeted naloxone distribution, a harm reduction intervention, appears to be the under-funded opportunity with the greatest unmet life-saving potential. But, if others have evidence for an alternative approach that has a higher probability of achieving larger results faster, we absolutely want to know. We are completely open to changing our funding priorities in response to better evidence.
Our judgement to pursue SAP-facilitated naloxone distribution as our first funding effort was based on imperfect evidence. However, we believe it was well-founded. Here is some of the evidence we consulted in our decision to target SAP-facilitated naloxone distribution as our best choice for OCRF’s first area of funding.
Targeted naloxone distribution is the largest unmet opportunity to reduce opioid overdose fatality, surpassing medication assisted treatment, pain medication prescribing restrictions, and prescription monitoring programs.
Mattson CL, O’Donnell J, Kariisa M, Seth P, Scholl L, Gladden RM. Opportunities to Prevent Overdose Deaths Involving Prescription and Illicit Opioids, 11 States, July 2016–June 2017. MMWR Morb Mortal Wkly Rep 2018;67:945–951. DOI: http://dx.doi.org/10.15585/mmwr.mm6734a2.
Bystanders to overdose, who could potentially intervene, were documented in 44% of deaths; however, laypersons rarely administered naloxone.
A nation-wide study found that more than 80% of overdose reversals with naloxone in the U.S. were carried out by individuals who also use drugs.
An observational study of a naloxone distribution program in British Columbia indicated that at least one in every ten kits distributed to people who use drugs had saved a life.
93% of nonfatal opioid overdose survivors were still alive 1 year post-overdose—indicating saving a life with naloxone today isn’t simply delaying a death until next week.
Research purporting to demonstrate that naloxone distribution encourages riskier drug use (i.e. moral hazard), to the extent that the net result is higher fatality, is not credible.
Naloxone distribution to heroin users is cost-effective, even under markedly conservative assumptions.
Time – OCRF deployed six naloxone supply grants to six syringe access programs (SAPs) in October of 2018. For the sake of estimating the impact of these grants for the period between 10/1/2018 and 6/30/2019, we calculated on the basis of 273 days.
Money – The total expenditures of OCRF during the grant period were $133,508. These expenditures were not only the funds OCRF provided as grants. They are the total expenses of OCRF during the 9-month period, including employee expense, fundraising, promotional activities, and finance and administrative expense.
Reported Overdose Reversals – OCRF collected reports from grantees on a quarterly basis following the initial grant dates. In these grant reports, we asked SAPs to provide the number of overdose reversals their clients reported performing with the naloxone the SAPs had supplied. These reports are collected by SAPs when clients return to the SAP for naloxone refills. In computing how many overdose reversals OCRF funding made possible, we noted the supply of naloxone inventory a grantee already had in stock prior to OCRF funding, plus how much inventory came in through means other than OCRF funding, and subtracted a proportional number of overdose reversals from the total reported by the grantee to derive the number that was due to OCRF funding.
During the period between 10/1/2018 and 6/30/2019, grantees reported 983 overdose reversals that could be ascribed to OCRF funding. All of these reversals were reported by only four of our six grantees. Of these four SAPs, one was only able to begin using OCRF funds for naloxone distribution in March 2019. Of the two SAPs from which we had no reported reversals, one of our grantees is unable to systematically collect reports of overdose reversals from its clients due to the law enforcement environment in which it operates (documentation of overdose reversals is treated as evidence of a crime), and one grantee had not begun to spend its grant funding by 6/30/2019.
Lives-Saved per Day – By dividing 983 overdose reversals by 273 days, we derive a rate of 3.6 lives-saved per day through OCRF funding. This rate of effectiveness could be driven substantially higher in at least two ways: 1) if all of our grantees, instead of only four, could have facilitated and reported overdose reversals during the 9m period, and 2) if OCRF had been able to provide more money to SAPs capable of facilitating and reporting overdose reversals. Nationwide, there is still ample opportunity improve this hurdle rate via item #2. A recent national survey of SAPs engaged in naloxone distribution found that, due to insufficient funding, at least 70 are currently rationing client access to naloxone.
Cost per Life-Saved – By dividing OCRF’s total expenditures of $133,508 from 10/1/18 through 6/30/19 by 983 reported overdose reversals, we derived a cost of $135.86 per life-saved. There are a number of ways this rate of effectiveness could have been substantially better, including if all of our grantees, instead of only four, could have generated and reported overdose reversals during the 9m period.
Reported overdose reversals collected by SAPs may be inaccurate – There are a justifiable grounds for assuming the actual number of overdose reversals facilitated by SAPs could be either higher or lower than the number that is reported back to them by clients. The researchers we have spoken to assume that actual overdoses facilitated by SAPs is higher than the reported number, for two reasons: 1) clients don’t report when they reverse overdoses, because they don’t want to provide documentary evidence of participation in illegal activity that could lead to follow up from law enforcement, and 2) clients who have rescued others from overdose may never return to the SAP because they entered recovery, are incarcerated, or are no longer local.
Naloxone distribution through SAPs is futile. The person that naloxone saves this week is just going to die of an overdose anyway in a matter of weeks or months. – A study, published in JAMA in August 2018, of causes of death in 76,325 Medicaid beneficiaries following non-fatal opioid overdose found that 93% of this population was still alive 1 year post-overdose. Naloxone does not simply delay an inevitable death. In addition to preventing death in the short-term, it buys potentially years of time for people to engage treatment and recovery supports.
Providing naloxone to people who use drugs only encourages them to engage in riskier drug use (the moral hazard, or “enabling,” argument) – This argument is intuitive to people without a personal history of drug use. There is no proof it is true, and substantial evidence it is not. The most prominent study to advance the moral hazard argument (which did not include a literature review of existing studies of naloxone distribution) led researchers from Harvard, Stanford, and the University of Chicago to collaborate to publish a review of the study discrediting its purported findings, and urging policy-makers to disregard it. Further, head-to-head research of neighboring communities in Massachusetts that did and did not establish naloxone distribution programs showed that overdose death rates were lower in communities that established naloxone distribution programs.
Invitation to Discuss:
Please contact firstname.lastname@example.org with any questions. We are completely open to discussing how we work, and to absorbing any criticism. If others have proof of better ways to save as many lives as possible, as quickly as possible, from opioid fatality…we want to know. We are completely open to changing our funding priorities in response to evidence of better opportunities.