“If It Didn’t Get Reported, It Didn’t Happen”: Current Nonfatal Overdose Reporting Practices Among Nontraditional Reporters in Texas

Abstract

Background.

Drug overdose deaths in Texas have been accelerating in recent years with an increase of 33% in the 12 months leading up to December 2020. Accurate counts of nonfatal overdoses – including associated aspects of overdose, such as substances involved, demographic information, and reversal agents administered is critical to increase timely and adequate response to individuals and communities in need.

Methods.

Twenty semi-structured interviews were conducted with harm reduction workers across four Texas counties to understand existing methods of reporting overdoses, naloxone dissemination/administration, and recommendations for improving overdose surveillance. Interviews were transcribed and emergent themes were identified based on the a priori research goals.

Results.

Findings highlighted a variety of overdose data collection methods and tools among harm reduction organizations including Excel spreadsheet, web-based TONI application, notes on personal cell phones, and paper notes. Types of overdose data collected varied widely. Participants noted existing methods are suboptimal and that there is a need for a unified, statewide reporting system to improve overdose data capture. Participants also highlighted that overdose surveillance should include “hidden populations” of people who use drugs that are not currently counted in surveillance methods as a result of not interacting with the healthcare system.

Conclusions.

Texas lacks a unified overdose reporting system to capture critical data to inform overdose response and prevention efforts. Non-traditional reporters may be critical towards improving overdose syndromic efforts and capturing data among hard-to-reach populations. Harm reduction organizations are uniquely positioned to facilitate reporting among community gatekeepers and people who use drugs.

1. Introduction

Drug overdose deaths in Texas have been accelerating in recent years. Provisional data from the Centers for Disease Control and Prevention (CDC) (Ahmad et al., 2021) showed an increase of 33% in the 12 months leading up to December 2020, compared with the 12 months leading up to December 2019. Any opioid overdose deaths increased 44%, and synthetic opioid-related deaths increased 170%. Accurate counts of nonfatal overdoses – including associated aspects of overdose, such as substances involved, demographic information, and reversal agents administered is critical to increase timely and adequate response to individuals and communities in need.

However, collecting an accurate count of nonfatal overdoses and disseminating that information to stakeholders is challenging. Research suggests that only a small proportion of nonfatal overdoses (Ellis et al., 2020; Koester et al., 2017; Wagner et al., 2019) are reported to emergency medical services (EMS). Even if an individual presents at an emergency department (ED) for a nonfatal overdose, it can take up to two years for that data to reach the community because surveillance is often based on ED claims data (National Center for Injury Prevention and Control, 2019).

Recent federal initiatives have focused on improving the timeliness of nonfatal overdose reporting through the expansion of data sources such as EMS naloxone administration and syndromic surveillance (Rock et al., 2021). Nevertheless, these efforts do not address the challenge of documenting nonfatal overdoses among individuals who do not contact EMS. Engaging “nontraditional” first responders, such as people who use drugs (PWUD) and community organizations that engage in harm reduction efforts, could help fill this gap in surveillance. This research brief elaborates current approaches to nonfatal overdose reporting among nontraditional reporters (harm reduction coalition [HRC] members and PWUD) in Texas and proposes an alternative to enhance reporting among HRC members and PWUD.

2. Material and methods

This examination of overdose reporting practices among HRC and PWUD was conducted as part of a larger study to improve overdose tracking through developing a community-based digital platform for overdose reporting and response among harm reduction organizations. A community-engaged research approach was used to form community advisory boards (CAB) of key stakeholders across four counties in Texas. Key stakeholders included HRC leaders and representatives from other organizations in the field such as first responders and treatment providers.

2.1. Recruitment

Using a snowball recruitment method, the research team conducted 20 interviews with HRC (via referrals from the CAB and other organizations). Research team members screened participants by phone or email using the following eligibility criteria: 1) volunteer or paid staff member for a harm reduction organization; 2) 18 years or older; and 3) ability to read and speak in English. Informed consent was obtained for HRC who met the criteria and agreed to participate. 60% of participants identified as white/Caucasian, 15% as Hispanic/Latinx/Mexican, 10% as Black/African-American, and 15% as mixed races. Ages ranged from 22 years to 67 years.

2.2. Procedures

Semi-structured interviews were conducted with HRC via videoconference, telephone, or in-person. Topics included existing methods of reporting overdoses and naloxone dissemination/administration, description of the most recent overdose report completed (e.g., administration process, length of time, data elements), and recommendations for improving the process. Interviews lasted about 82 minutes on average, with a range of 62 to 95 minutes.

2.3. Analysis

Interviews were transcribed and emergent themes were identified based on the a priori research goals. A working codebook and framework matrix was generated based on the themes. The transcripts were then independently and concurrently coded by two coders in NVivo12 using the deductive codebook. Code reports followed by inductive phase using analytic matrix display were used to summarize emerging themes.

3. Results

3.1. Tools for Reporting Nonfatal Overdose

Nontraditional reporters in Texas currently use varied tools for reporting nonfatal overdoses. Interviewees identified several tools that they and PWUD use most frequently, including the Texas Overdose Naloxone Initiative (TONI) web-based app and electronic or paper forms. Less commonly used tools included an organization’s electronic health records (EHR), cell phone notes or personal notes (not followed by electronic entry). One indicated that their organization did not have an established system. Table 1 displays the tools, challenges with the tools, and illustrative data from interviewees.

Table 1.

Tools Used for Nonfatal Overdose Reporting by Harm Reduction Coalition Staff and People Who Use Drugs in Texas

Tool	Challenges	Data
Texas Overdose Naloxone Initiative (TONI) app developed by a harm reduction volunteer	• Technological barriers (e.g., need web access or newer smartphone to enter data, need enough data minutes on the phone) • Extensive data entry required, which is burdensome	“[TONI] is meant for more updated phones, and so then I have to log onto the website and log in, and so that process isn’t very streamlined anyway.” (Outreach Coordinator, female, white)
Electronic form (data collected on tablet or other device in the field)	• HRC staff lack time to collect data in the field while delivering services • Lack of computer skills and training to enter data • Form unique to organization (cannot be easily harmonized with other data sources)	“I just use an Excel spreadsheet to track everything. I’m not very computer literate.” (Outreach Specialist, male, white) “I had the form on my computer and then after I encountered somebody that performed any kind of harm reduction, I would jot it into the spreadsheet with the intention of trading that in back to [Coworker]. He was gonna be the one who was compiling them.” (Lead Peer Recovery Support Specialist, female, multiple racial identities)
Paper forms	• HRC staff lack of time to collect data in the field while delivering services • Lack of computer skills and training to enter data • Form unique to organization (cannot be easily harmonized with other data sources) • Entry into electronic database may be delayed or may not occur	“What we do is on paper ’cause it’s when we do outreach and… [we then] transcrib[e] that [nonfatal overdose information] into the online database. We’re backed up since, like, November…. After we do our outreach notes, we transcribe it onto paper and then that into the data form.” (Project Coordinator, male, Hispanic/white)
Electronic health records (EHR)	• Only captures a client’s experience at clinical intake	“It’s called [proprietary EHR]—and it’s what we use to document all of our interactions with clients…. Then their treatment plan is being created based on a comprehensive biopsychosocial assessment. So all of that information is being documented and entered into their chart…. What we don’t do and what we should probably be doing is then following up with whatever mechanism is in place in the community for tracking that to see if that maps onto what they have and sharing data with them.” (Regional Impact Manager, male, white)
Cell phone or personal notes	• Unclear how the information is used • May not be entered into electronic database • Potential privacy and data security issues • Unique to individual who records information	“Basically, I just jot it [information about a nonfatal overdose] down.” (Peer Recovery Support Specialist, transgender, Hispanic) “I kinda rely on just recording my own data, which comes with its own problems.” (Outreach Specialist, male, white)

3.2. Data Collection Practices for Collecting Information on Nonfatal Overdose

In addition to the tools they use, interviewees shared several practices for collecting data or approximating nonfatal overdoses in their communities. These practices included conducting outreach to PWUD and counting supplies used or distributed. Outreach to PWUD entailed either A) actively engaging PWUD in discussions about their experiences with or observations of nonfatal overdoses or B) documenting nonfatal overdoses when clients at the harm reduction site happened to mention experiencing or witnessing a nonfatal overdose. One interviewee explained how staff at his organization actively seek information about nonfatal overdose:

Most of the overdoses we hear of are from our regulars and through street outreach. So based on that and how much Narcan that we usually provide them, most [of] the people that tell us that they have experienced or been around that…We typically ask if they themselves overdosed or if they’ve been around other people that have overdosed, if they used Narcan in that instance or how they responded to it. And we ask them usually, I usually like to ask them about within a week [did you experience or observe an overdose]. (Project Supervisor/Outreach Coordinator, male, white/Asian).

Several interviewees discussed using counts of supplies distributed as a proxy for nonfatal overdoses, and one interviewee said that in their organization, they count the empty vials that are returned to them to roughly determine the number of nonfatal overdoses in their community.

Across most of the tools and practices, however, interviewees noted that the current tools and practices are not optimal or comprehensive and have multiple challenges (Table 1). Interviewees recognized the value of having a more robust reporting system and set of practices. As one said, “If there was a statewide, centralized database that was really easy to use, we could access that and bounce our information off of that” (Project Coordinator, female, white).

4. Discussion

Public health initiatives rely on accurate and reliable data to develop and implement data-driven solutions. The existing overdose data infrastructure is limited by several factors including: (a) disparate reporting systems; (b) failure to capture “hidden” populations who do not come into contact with the health care system; (c) timeliness of data capture; and (d) lack of interoperability of data systems. Nontraditional reporters are key to improving data capture among hidden populations. However, the current tools and approaches available to nontraditional reporters are inconsistently used and fragmented, which means unreliable, invalid data. In some instances, the data may remain on paper or in someone’s phone, which presents data security concerns and gaps in data capture. Improved overdose surveillance tools designed for nontraditional reporters will facilitate data-driven community response and overdose prevention efforts. These data can help harm reduction organizations improve their outreach efforts and learn from each other: “It would be much more helpful to have the statewide picture, where we could see how—you know, what we’re seeing in comparison to what other people are seeing” (Policy Director, female, white).

New tools that are low burden, easy to use, and accessible are essential for developing a comprehensive reporting system that engages nontraditional reporters. Harm reduction organizations are ideal for implementing such tools as they have regular access with hard-to-reach PWUD and have established trust within the community. One harm reductionist noted, “We’re putting Narcan in other people’s hands. We might as well put the reporting piece in their hands as well” (Outreach Coordinator, female, white). This highlights harm reduction organizations’ unique position to potentially facilitate reporting among community gatekeepers and PWUD. Importantly, new tools must draw on community engagement and a co-design process to ensure that it is relevant and feasible for nontraditional reporters as well as ultimately ensure buy-in and uptake. The development process should take a trauma-informed approach as reporting overdoses may be a trigger among witnesses. Ideally, new tools need to be developed with interoperability in mind to facilitate integration with traditional data sources. Finally, framing around reporting should be positive to incentivize reporting (e.g., heroic act/helping to save lives), rather than “overdose reporting.” In Texas, Project CONNECT and TxCOPE.org [Texans Connecting Overdose Prevention Efforts] are emerging as a robust tool developed through community-academic-industry co-design process that accomplishes these objectives.

4.1. Limitations

Results from this study should be taken in light of several limitations. This study focused on semi-structured interviews with staff and volunteers in harm reduction organizations across four counties in Texas including Travis County (Austin), Bexar County (San Antonio), El Paso County, and Williamson County (rural, north of Austin). As such, the extent to which these tools or approaches are used cannot be determined; this article may not capture all tools and approaches used throughout the state of Texas. Further, these interviews were conducted with HRC staff who may not know of all reporting practices PWUD use; however, many HRC staff include people who are in recovery from a substance use disorder.

5. Conclusion

Existing nonfatal overdose reporting practices among traditional and nontraditional reporters remains fragmented, which limits data quality as well as constrains what policy decisions should be made and how to mobilize resources efficiently and effectively. Integrating nontraditional reporters systematically into nonfatal overdose reporting can enhance existing reporting systems through improving timeliness of data capture (e.g., near real time) and is essential for better identification of emerging issues in a community. These data are critical to developing data-driven resource allocation and may help to improve the sustainability of harm reduction organizations through the provision of better data highlighting the impact of their work and facilitating funding opportunities.

Community overdose response initiatives should be data-driven in order to increase efficiency of response and effective allocation of limited resources. Integrating nontraditional reporters will provide more real-time information to support rapid response and may provide additional context to understand local circumstances surrounding overdose. New tools, such as TxCOPE.org, developed based on stakeholder engagement offers a widely available, centralized database that is easy to use and accessible. This could be a model for other states seeking to improve data-drive community response efforts pertaining to overdose.