Evaluating the Impact of Brave Technology Co-op’s Novel Drug Overdose Detection and Response Devices in North America: a Retrospective Study

Abstract

Assess the preliminary impact of Brave Technology Co-op’s overdose detection devices that have been implemented in housing, medical, social service facilities, and several private settings in North America. Administrative data was collected by Brave on their Buttons and Sensors during several proof-of-concept projects and full installations in Canada and United States (US) between December 2018 and July 2022. Data analyzed provided insights on the number of overdoses detected and reversed (averted overdose deaths) using Brave Sensors and Buttons, along with other programmatic and session-specific indicators. Implementation of 486 Brave Buttons and 148 Brave Sensors in Canada has detected and prevented 108 overdose deaths (100 using Buttons and 8 using Sensors) whereas implementation of 170 Buttons in the US has averted 2 overdose deaths to date, with the potential to save many more lives. Brave’s devices hold promise for increasing rates of overdose detection and preventing overdose deaths.

Introduction

While tremendous strides have been made to prevent drug overdose fatalities through initiatives such as substance use treatment, recovery services, and naloxone distribution, the overdose crisis continues in part due to persistent social, structural, and medical vulnerabilities among people who use drugs (PWUD). These barriers include stigma, poverty, homelessness, criminalization, unmet mental health needs, and barriers to healthcare access [1]. In examining gaps in the current response to the overdose crisis, there is a notable lack of innovation surrounding the speed and rate at which overdoses are detected in the community, especially in the context of rising fentanyl- and stimulant-involved overdoses observed across North America [2].

Another unaddressed issue has been solitary drug use, a relatively commonplace practice among individuals at risk of overdose, albeit an issue that remains poorly studied. US-based studies conducted among PWUD found that close to half reported using drugs alone, which reduces opportunities for bystander intervention [3, 4]. PWUD report engaging in solitary drug use for a variety of reasons, including to minimize external noises, distractions, and social influences to optimize their experiences using drugs [5]. Interventions that enhance existing community-based strategies for overdose detection and response could reduce gaps in responses to solitary overdose events. In the absence of formal intervention, some organizations, including syringe services programs (SSP), have implemented safety procedures, such as manually conducting regular bathroom checks to monitor for potential overdoses happening on their premises. However, these approaches are time-intensive, susceptible to human error, and limited by staff capacity which make them unsustainable as long-term solutions. Similarly, some PWUD have implemented peer-based surveillance networks, coined “drug spotting,” to facilitate detection and rapid response to potential overdoses [6]. While supervised consumption spaces could greatly facilitate overdose response and linkage to care efforts, only one state in US (Rhode Island) has legally sanctioned such venues [7]. Such experiences highlight large gaps and opportunities for overdose prevention efforts.

Novel overdose detection technologies hold promise for decreasing rates of community-based overdose morbidity and mortality [8–10]. Some technologies used to address solitary drug use include Never Use Alone hotline (i.e., an anonymous 24/7 hotline that people who plan to use drugs can call and be monitored by trained operators that check on them and call EMS in the event of an emergency), Canary app (i.e., a smartphone app that monitor a user’s inactivity using an accelerometer and sends alerts to others in the event of a potential overdose), automatic antidote delivery device (i.e., a proof-of-concept wearable naloxone auto-injector), and anti-motion detectors (i.e., device is currently unavailable but sensors work by sounding an alarm with bright lights flashing above the door in the event of an overdose emergency rather than alerting nearby staff via text message) [8]. Each of these technologies are impactful but not comprehensive when compared to the suite of overdose detection and response tools (i.e., tailored to the needs of communities with lived experience) developed by Brave Technology Co-op (Brave). Brave is a Canadian peer-led cooperative focused on improving overdose detection and response through innovative technologies combined with community engagement [11, 12]. Brave is composed of a network of developers, engineers, designers, and people with lived and living experience around drug use. Brave has developed several early warning technologies, including Brave Button and Brave Sensor, which are the focus of the present study.

Brave Buttons are small wireless devices that can be wall-mounted inside single-occupancy units within supportive housing facilities, where building staff or peer supporters are available onsite to respond in the event of an overdose. Device is activated by residents to request an in-person check-in from onsite staff member, or pressed twice or more to obtain an immediate response in case of overdose or any other emergency. Brave Sensor is a device designed for bathrooms and uses ultra-sensitive radar sensors to detect the reduction of movements in an enclosed space, such as a bathroom of a supportive housing facility for people with substance use disorder. When the radar sensor detects reduced motions, the system will promptly alert an onsite designated responder (onsite staff or volunteers). Brave tools are more effective and less prone to limitations that exist in existing overdose prevention technologies and interventions. Brave tools make efficient use of workers’ time (i.e., they no longer have to check the bathroom at random times of the workday which could lead to fatigue and missed opportunities to detect actual emergencies), are less susceptible to human error (i.e., it is the Brave Sensor that initiates the alert to staff triggering a response), and can improve onsite staff ability to avert an overdose or other medical emergency. All of Brave’s tools connect an individual at imminent risk of an overdose to immediate support if they are non-responsive within a short timeframe (typically 3 min).

In this paper, we present findings from a retrospective analysis of the implementation of Brave’s devices from several proof-of-concept and full installation projects in US and Canada. We discuss the potential utility of these technologies as a public health approach to mitigating drug overdose mortality.

Methods

Administrative data was collected by Brave Technology Co-Op on Brave Button and Brave Sensor during several proof-of-concept projects and full installations in Canada and US between December 2018 and July 2022. Collected data include the duration in which devices were active, number of organizations that received devices, and how many devices were issued. Furthermore, administrative data captured information on the building types where devices were installed, number of devices that are activated (a device that has been installed but may or may not be functional/operational), total number of sessions (incidents) that occurred in each country, staff awareness of incident and progress made to document the incident type, and whether incident was resolved by staff. Lastly, administrative data collected information on the median response time (in seconds) of device sessions (timestamp from when a session started to response), median number of times Brave Button were pressed for the sessions, and incident type reported for device sessions (categorization assigned to an incident by the responder; overdose occurrence was the main outcome of interest). Data collected were cleaned and analyzed using SAS 9.4 software (SAS Institute, Cary, NC, USA).

Results

Brave Device Implementation and Overview of Devices Sessions in North America, 2018–2022

Table 1 provides a description of Brave device installations, both proof-of-concept and full, to 18 organizations in Canada and US. From December 2018 to July 2022, 486 Brave Buttons were issued to 16 organizations in Canada (median: 27 Buttons per organization) and 170 Brave Buttons were issued to two organizations in US (median: 85 Buttons per organization). Most of Brave Button issued to Canadian organizations were installed in supportive housing facilities with single-room occupancy (68.8%), and nearly all Buttons were activated (87.5%) as of July 2022. All Brave Buttons given to US organizations were implemented in supportive housing with single-room occupancy and were activated as of July 2022.

Table 1.

Description of Brave devices from proof-of-concept to full implementation and overview of sessions generated by Brave devices in North America, 2018–2022

Implementation characteristics	Brave Button		Brave Sensor
Country (first year of implementation)	Canada (2018)	United States (2021)	Canada (2019)
Building type where devices were installed
Supportive housing: single-room occupancy	11 (68.8%)	2 (100%)	9 (26.5%)
Shelter housing: multiple occupancy	1 (6.3%)	-	3 (8.8%)
Medical: community health care facility	-	-	8 (23.5%)
Medical: acute care hospital facility	1 (6.3%)	-	1 (2.9%)
Medical: overdose prevention sites/supervised consumption spaces	1 (6.3%)	-	4 (11.8%)
Community-based drop-in center	-	-	5 (14.7%)
Government: library	-	-	2 (5.9%)
Retail: food and beverage	-	-	1 (2.9%)
Total number of sessions	4997	208	14,251
Median recorded response time	73 seconds	432 seconds	48 s
Median (range) number of times buttons were pressed per session	2 (1-259)	1 (1-242)	-
Staff awareness of sessions	4872 (97.5%)	119 (57.2%)	6857 (48.1%)
Staff resolved sessions	4306 (86.2%)	82 (39.4%)	5140 (36.1%)
Incident type reported for devices sessions
Overdose	100 (2.0%)	2 (1.0%)	8 (0.1%)
Mental/physical health issues	4 (0.1%)	2 (1.0%)	-
Conflict resolution	180 (3.6%)	9 (4.3%)	-
Connections to care	4 (0.1%)	7 (3.4%)	-
Confidential	4490 (89.9%)	185 (88.9%)	9358 (65.7%)
Safer use	219 (4.4%)	3 (1.4%)	-
Person responded	-	-	3123 (21.9%)
No one inside	-	-	1762 (12.4%)

As of July 2022, sensors have not been launched in the US; sessions refer to any incident that resulted in a text alert during device usage; median response time of device sessions is the real-time system timestamp from session start to response

As of July 2022, 34 organizations in Canada purchased and received Brave Sensors. One hundred forty-eight Brave Sensors were issued to Canadian organizations (median: 4 Sensors per organization). Most of the Brave Sensors were installed in supportive housing with single-room occupancy (26.5%) or community healthcare facilities (23.5%), and most were activated (65.7%) as of July 2022.

Table 1 also presents information on Brave device sessions reported in Canada and US during the study period. Five thousand two hundred five Brave Button sessions were observed in Canada (n = 4,997) and US (n = 208). Responders were aware of 4872 (97.5%) of Brave Button sessions in Canada, with a majority (n = 4306, 86.2%) resolved by responders. Responders were aware of 119 (57.2%) of Brave Button sessions in US; most of which were resolved by responders (n = 82, 39.4%). Median response time for Brave Button sessions was substantially faster in Canada than in US (73 s in Canada; 432 s in US). The median number of times Brave Buttons were pressed in a single device session was slightly higher in Canada than US (twice in Canada versus once in US). More overdose incidents were reported for Brave Button sessions in Canada than in US (100 overdose incidents in Canada; two in US). During the study period, 14,251 Brave Sensor sessions were observed by Canadian organizations. Staff were aware of 6857 (48.1%) of Brave Sensor sessions that occurred in Canada. Median response time for these sessions was 48 s. Eight (n = 8; 0.1%) overdose incidents were reported for Brave Sensor sessions in Canada. Staff resolved 5140 (36.1%) of Brave Sensor sessions.

Discussion

Overdose detection technologies hold potential in greatly reducing drug overdose deaths in US and Canada. These technologies complement existing strategies such as naloxone distribution by reducing response times, facilitating referrals to care and averting overdose deaths [11, 12]. The current study focused on Brave’s devices, which have been developed in close collaboration with PWUD [12]. We found that over 100 lives have already been saved using Brave Technology Co-op’s Buttons and Sensors. Results from this preliminary cross-sectional analysis reveal that Brave’s devices are being used in a variety of non-traditional settings (multi-unit supportive housing) and are helping to improve the overdose detection capability among frontline staff. More studies will be required to evaluate the effectiveness, costs, and implementation differences between settings (country and type of location) and populations served. For example, we noted that response times and outcome reporting were better among projects in Canada. Differences in response times between US and Canada may likely be a result of training. These early findings also demonstrate that Brave’s devices are making a positive impact in the fight to curb the drug overdose epidemic and warrant further evaluation.

The study has several limitations. First, a lack of staff capacity and staff turnover at some organizations hindered them from monitoring and detecting drug overdoses on a consistent basis. Second, underreporting of overdoses may have occurred due to concerns around confidentiality and potential repercussions (eviction, loss of funding). Third, outcomes of many sessions remained unrecorded in Brave’s data system, which may have biased the prevalence estimates. Despite these limitations, this study highlights potential of overdose detection technologies to prevent the risks associated with solitary drug use. Brave continues to prevent overdose deaths today and has plans to launch new partnerships with organizations so they can expand the use of its tools across the globe.