NEXT Harm Reduction: An Online, Mail-Based Naloxone Distribution and Harm-Reduction Program

Abstract

Needle EXchange Technology (NEXT) Harm Reduction is an online, mail-based platform designed for sending (1) naloxone kits to people at risk for overdose and (2) sterile syringes and other equipment directly to people who otherwise cannot access safe supplies. From its inception in 2017 through the end of 2019, NEXT Harm Reduction sent naloxone kits to 3609 individuals and 1230 packages of sterile syringes and supplies and received 335 reports of overdose reversals using naloxone provided by NEXT Harm Reduction and its affiliates.

In this article, we describe the purpose, implementation, impact, and public health significance of Needle EXchange Technology (NEXT) Harm Reduction and outline challenges and opportunities to inform other organizations who may be interested in expanding or integrating online, mail-based harm-reduction services in their communities.

INTERVENTION

NEXT Harm Reduction is an online, mail-based platform designed to reduce opioid overdose deaths; prevent injection-related transmission of conditions including HIV, hepatitis C, and soft tissue bacterial infections; and improve the lives of people who use drugs and their loved ones.¹ It is a 501(c)(3) organization originally sponsored by the Harm Reduction Coalition.

NEXT Harm Reduction runs two programs: NEXT Naloxone, which provides online overdose prevention education and mail-delivered naloxone kits to the loved ones of people at risk for overdose, and NEXT Distro, which mails sterile syringes and other drug use equipment, as well as naloxone, directly to people who otherwise cannot access safe supplies. Both programs are accessible via https://nextdistro.org. (Before October 2020, NEXT Naloxone’s Web page was https://www.naloxoneforall.org, which now redirects to https://nextdistro.org.)

PLACE AND TIME

Through a network of harm-reduction agencies and health departments, NEXT serves participants in all 50 states; Washington, District of Columbia; and Puerto Rico. It is based in New York City, where it is a registered New York State Opioid Overdose Prevention Program and Syringe Exchange Program. NEXT Distro began services in February 2018 and NEXT Naloxone began services in November 2018. It was inspired by the work of Tracey Helton and conversations at the 2016 National Harm Reduction Coalition Conference in San Diego, California.

PERSON

NEXT targets people who use drugs and their loved ones who are not able to access naloxone or sterile syringes and other resources for safer drug use in their local communities.

PURPOSE

Many people in the United States still have little or no access to naloxone (brand name: Narcan), the Food and Drug Administration–approved medication that prevents opioid overdose death by reversing opioid-induced respiratory depression.² Furthermore, people who use drugs still face physical, legal, and societal barriers to supplies for safer drug use. Stigma against and criminalization of drug use continues to prevent many people from accessing lifesaving resources even when they are available.³ As smartphone and Internet use becomes more accessible, people are increasingly using the Internet to obtain health information, medications, and supplies.⁴

IMPLEMENTATION

Program participants typically learn about NEXT Naloxone through social media (48%) and personal connections (23%; Table 1). This information was not systematically collected from NEXT Distro participants to reduce program and participant burden.

TABLE 1—

Demographics and Overdose Experiences of NEXT Naloxone Requesters: United States and Puerto Rico: November 2018–December 2019

	New Requests, No. (%)
Age, y
< 26	848 (22)
26–45	2352 (60)
46–65	677 (17)
> 65	43 (1)
Gender identitya
Male	1334 (34)
Female	2390 (61)
Gender nonconforming or nonbinary	141 (4)
Transgender	43 (1)
Racial/ethnic identitya
White or Caucasian	3448 (88)
Black or African American	119 (3)
Hispanic or Latinx	278 (7)
Asian	104 (3)
American Indian or Alaska Native	67 (2)
Native Hawaiian or Pacific Islander	24 (1)
Overdose experience in past year
Witnessed	2162 (55)
Has overdosed	344 (9)
Region: Northeastb
Total requests	771 (20)
Filled (% of total)	672 (87)
Diverted to local programs (% of total)	53 (7)
Region: Midwestc
Total requests	1132 (29)
Filled (% of total)	1046 (92)
Diverted to local programs (% of total)	34 (3)
Region: South and Puerto Ricod
Total requests	1349 (34)
Filled (% of total)	1262 (94)
Diverted to local programs (% of total)	31 (2)
Region: Weste
Total requests	674 (17)
Filled (% of total)	629 (93)
Diverted to local programs (% of total)	31 (5)
How requester heard about NEXT Naloxonef
Social media	1889 (48)
Personal connection	910 (23)
Online search or Web site	680 (17)
Recovery or support group	178 (5)

Note. The sample size was 3926.

^aPeople could select more than one response option for racial/ethnic and gender identity.

^bNortheast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont.

^cMidwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin.

^dSouth and Puerto Rico: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virginia, and West Virginia.

^eWest: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming.

^fBased on free text responses to the question “How did you hear about NEXT Naloxone?”; response categories are not mutually exclusive (e.g., “Facebook friend” would count as social media and personal connection).

Along with mailing supplies, NEXT programs include a handwritten note and informational materials in each package. Web pages and other written materials are offered in English and Spanish. Participants can also request referrals to other support services in their area, including buprenorphine providers, harm reduction–oriented physicians, and mental health services.

Postage for NEXT is paid for through grant funding and donations. NEXT sends packages through the US Postal Service priority mail, which typically take two to four days to arrive to participants.

NEXT Naloxone

Upon arriving on the NEXT Naloxone Web page, participants select which state they reside in and are directed to a state-specific resource page. If they are unable to access resources in their state, participants can watch a training video on overdose recognition and naloxone use, then fill out a secure online form to request naloxone via mail. In states where NEXT Naloxone has a partner affiliate (typically a local harm-reduction organization that already distributes naloxone within their state), NEXT forwards the request to the affiliate to coordinate and fulfill the delivery. Partner affiliates have signed memoranda of understanding with NEXT, which include terms of participant confidentiality and expected turnaround times for requests to be mailed out.

NEXT offers both intramuscular naloxone vials with syringes and intranasal Narcan-brand naloxone. The type and amount of naloxone sent to each participant depends on their request, level of overdose risk, state of residence, and available inventory (typically two to four doses, or more for individuals at higher risk for overdose).

NEXT Distro

To access NEXT Distro services, people connect via the program Web site (https://nextdistro.org) or reach out directly via e-mail, text message, or social media (Instagram: @nextdistro; Reddit: u/nextdistro). NEXT Distro then sends participants a link to the enrollment request form. Depending on what participants request, packages mailed to them contain supplies typically available at in-person harm-reduction programs: packs of syringes available in multiple sizes, hazardous material bins, cookers and cotton, and safer smoking, safer sex, and wound care supplies.

EVALUATION

From November 2018 through December 2019, NEXT Naloxone received 3926 new requests via https://www.naloxoneforall.org (Table 1). Of these, 3609 (92%) were filled by NEXT Naloxone (1812 directly, 1797 via affiliates), 149 (4%) were diverted to local programs, and 168 (4%) were undeliverable. From February 2018 to December 2019, NEXT Distro sent 1230 packages containing syringes and other supplies.

Each naloxone kit and package includes reminders with the link to an online form for participants to report back to the program if they have used the naloxone from NEXT to respond to an overdose and whether the reversal attempt of the overdose was successful. NEXT also e-mails periodic reminders to all participants who have received kits to report back to the program if they use their naloxone and may need refills. During this period, there were 353 participant reports of naloxone used to respond to an overdose, of which 335 (95%) were successful in reviving the person overdosing (Table 2). This is likely an underestimate as lay person overdose reversals are often underreported.⁵

TABLE 2—

Naloxone Use Reports to NEXT Harm Reduction: United States and Puerto Rico, November 2018–December 2019

	Naloxone Use Reports,a No. (%)
Did the person who overdosed survive?
Yes	335 (95)
No	9 (3)
Not sure	9 (3)
Relationship of person who reported overdose to person who overdosed
Friend or acquaintance	161 (46)
Family member or partner	84 (24)
Patient or client	6 (2)
Stranger	72 (20)
Unknown or prefer not to answer	30 (8)
Location of overdose
Home or apartment	238 (67)
Public - inside	21 (6)
Public - outside	58 (16)
Shelter or supportive housing	4 (1)
Other or unknown	32 (9)
Region
Northeastb	62 (18)
Midwestc	63 (18)
South and Puerto Ricod	188 (53)
Weste	40 (11)
Demographics of person who overdosed
Age, y
< 26	91 (26)
26–45	216 (61)
46–65	21 (6)
> 65	0 (0)
Unknown	25 (7)
Gender identity
Male	227 (64)
Female	100 (28)
Gender nonconforming or nonbinary	2 (1)
Transgender	3 (1)
Not reported	21 (6)
Racial/ethnic Identity
White or Caucasian	262 (74)
Black or African American	32 (9)
Hispanic or Latinx	21 (6)
Asian	5 (1)
American Indian or Alaska Native	8 (2)
Native Hawaiian or Pacific Islander	0 (0)
Previously experienced overdose
Yes	188 (53)
No or not sure	165 (47)

Note. The sample size was 353.

^aSome people reported multiple naloxone use reports.

^bNortheast: Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont.

^cMidwest: Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Missouri, Nebraska, North Dakota, Ohio, South Dakota, and Wisconsin.

^dSouth and Puerto Rico: Alabama, Arkansas, Delaware, District of Columbia, Florida, Georgia, Kentucky, Louisiana, Maryland, Mississippi, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virginia, and West Virginia.

^eWest: Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming.

A central limitation and concern of NEXT is that it is primarily reaching individuals who have a dependable mailing address and reliable access to the Internet, creating barriers for participants who are unhoused, unstably housed, or without Internet access.⁶ Furthermore, as program participant demographic data show, NEXT has had limited reach in communities of color at higher risk of experiencing or witnessing an overdose.⁷

ADVERSE EFFECTS

While NEXT has not received reports of adverse effects or unintended consequences, a primary concern is the confidentiality of participant information related to admission of substance use or interception of packages. To guard against this, NEXT does not connect participant enrollment data (i.e., names, addresses) with potentially sensitive substance use information. The processes of enrolling and requesting supplies are separated and connected through a participant-chosen “handle.” Furthermore, NEXT encourages participants to use encrypted messaging applications to communicate with the program. Nevertheless, many program participants report more concern about scarcity of syringes and naloxone than about potential privacy risks.

SUSTAINABILITY

The sustainability of NEXT is largely driven by affiliate partnerships based in communities where participants are requesting supplies. Affiliate partners are able to tailor delivery of supplies to local circumstances and can develop more direct supportive relationships with participants.

One concern of expansion via government partnerships is whether formalization will create barriers that prevent participants from electing to share their information. Government partners should be aware of this concern and ensure that identifying participant information is not used or distributed for any purpose beyond provision of supplies.

PUBLIC HEALTH SIGNIFICANCE

In the context of the opioid overdose crisis and ongoing HIV and hepatitis C epidemics, as well as active political opposition to local syringe access programs in many parts of the country, NEXT Harm Reduction provides an innovative platform for people who use drugs and others in their community to connect with low-barrier access to information, support, and life-saving medication and supplies.