Evidence-Based Strategies

for Preventing Opioid Overdose:

What’s Working in the United States

An introduction for public heath, law enforcement,

local organizations, and others striving to serve their community

Authors:

Jennifer J. Carroll, PhD, MPH; Traci C. Green, PhD, MSc; 

and Rita K. Noonan, PhD

2018

Contents

Introduction and Overview ....................................1

Guiding Principles ................................................3

Evidence-Based Strategies....................................7

Targeted Naloxone Distribution............................................8

Medication-Assisted Treatment (MAT) ..............................10

Academic Detailing ..........................................................12

Eliminating Prior-Authorization Requirements 

for Medications for Opioid Use Disorder............................14

Screening for Fentanyl in Routine Clinical 

Toxicology Testing..............................................................16

911 Good Samaritan Laws...............................................18

Naloxone Distribution in Treatment Centers 

and Criminal Justice Settings............................................20

MAT in Criminal Justice Settings and Upon Release ..........22

Initiating Buprenorphine-based MAT 

in Emergency Departments...............................................24

Syringe Services Programs................................................26

References.........................................................29
Acknowledgements

This document and its contents were reviewed by numerous subject matter experts. The authors would 

especially like to thank the following persons: Alice Asher, Grant Baldwin, Dita Broz, Deborah Dowell, Brian 

Edlin, Tamara M. Haegerich, John Halpin, Joann Yoon Kang, Reshma Mahendra, Philip Peters, Jessica Wolff, 

and Nick Zaller.

Suggested Citation:

Centers for Disease Control and Prevention. Evidence-Based Strategies for Preventing Opioid Overdose: What’s 

Working in the United States. National Center for Injury Prevention and Control, Centers for Disease Control 

and Prevention, U.S. Department of Health and Human Services, 2018. Accessed [date] from http://www.

cdc.gov/drugoverdose/pdf/pubs/2018-evidence-based-strategies.pdf.
Evidence-Based Strategies for Preventing Opioid Overdose: What’s Working in the United States, 2018 1

Introduction and Overview

Who is this document for?

This document is to assist community leaders, 

local and regional organizers, non-profit groups, law 

enforcement, public health, and members of the 

public in understanding and navigating effective 

strategies to prevent opioid overdose in their 

communities.

How can readers use this document?

Readers can use this document as a general 

reference for evidence-based practices that have 

been successfully implemented in the U.S. and are 

effective in reducing rates of opioid overdose. This 

document also provides readers with straightforward 

explanations of how and why these strategies work, 

summaries of major research on these topics, 

and examples of organizations from across the 

U.S. that have excelled at putting these strategies 

into practice.

How was this document created?

The selection of evidence-based strategies included 

in this document began with a systematic search 

of scientific literature on the prevention of opioid 

overdose in the context of prescription opioid 

misuse or use of illicit opioids. To be considered 

for inclusion in this document, strategies must 

have been successfully implemented in at least 

one jurisdiction in the U.S. as evidence for 

this document was being reviewed (between 

April and August 2017) AND meet one of the 

following evidentiary criteria: (1) meta-analyses 

or systematic reviews have found the strategy to 

be effective at reducing overdose and/or factors 

that increase overdose risk; (2) evidence from a 

scientifically rigorous experimental study, such 

as a randomized controlled trial, demonstrates 

the strategy’s effectiveness in reducing overdose 

and/or factors that increase overdose risk; or (3) 

multiple observational studies from U.S. settings 

indicate the strategy’s ability to reduce overdose or 

mitigate and reduce factors that increase overdose 

risk. In order to provide the broadest possible 

scope of evidence for guiding the implementation of 

overdose prevention strategies in the U.S., research 

that has been conducted in international settings 

that examines strategies also well-studied and 

proven feasible in U.S. settings are included in this 

document as well.

Based on these criteria, strategies identified can 

be considered promising or effective in reducing 

opioid overdose.

Over the course of several months, researchers, 

public health professionals, and subject matter 

experts were consulted to refine the list of strategies 

considered into a collection of those interventions 

with the strongest evidence of efficacy AND with 

demonstrated feasibility in U.S. settings. These 

contributors, including physicians, epidemiologists, 

sociologists, medical anthropologists, harm 

reductionists, and more, offered individual input based 

on their own research and experiences working at the 

forefront of the opioid crisis.

This is not an exhaustive list of overdose prevention 

strategies. Many countries—such as Canada, 

Portugal, The Netherlands, Germany, Switzerland, 

Norway, Australia, and Uruguay, just to name a few—

have implemented overdose-prevention policies and 

programs that have never been used in the U.S. Even 

within the U.S., many local organizers and advocates 

have developed unique, locally appropriate strategies 

too numerous to name here.

In sum, the strategies laid out in this document are 

well known, evidence-based actions that U.S. states 

and municipalities can take today to prevent new 

overdoses tomorrow.

Why evidence-based?

Opioid use disorders and opioid overdose are complex 

phenomena shaped by numerous social, biological, 

and psychological factors. Due to this complexity—

and the natural complexity of all human beings—fully 

understanding and accounting for all of these factors 

in an overdose prevention activity is a significant 

challenge. Often, ideas that once looked promising fail 

to pan out as expected.* There are also strategies 

that at first glance appeared counter-intuitive or 

wrong but were ultimately shown to be very effective 

in preventing fatal overdose. Subjecting overdose 

prevention interventions to scientific testing and 

evaluation is the only way to know for sure whether 

these intuitions are correct.

In acknowledgement of this pressing need, a 

practice is considered both “locally appropriate” 

and “evidence-based” if it has been designed in 

accordance with three key sources of information: 

(1) high quality scientific research; (2) the 

professional opinions and experiences of clinical 
2 Centers for Disease Control and Prevention | National Center for Injury Prevention and Control

and public health experts; and (3) the preferences, 

priorities, and values of the individuals who will be 

targeted or affected by that practice.1 By offering 

this summary of the current “best practices” for 

overdose prevention, based on a thorough review 

of existing research and expertise from a diverse 

array of medical and public health professionals, 

this document aims to fulfill areas 1 (scientific 

research) and 2 (expert opinions). Area 3, the 

preferences and priorities of those affected (in this 

case, individuals who use opioids or are otherwise 

at risk of opioid overdose), must be sought anew in 

each new community context. This combination of 

evidence, expertise, and community dialog will lay 

the groundwork for truly effective opioid overdose 

prevention strategies across the U.S.

* Research shows that some opioid use and overdose prevention interventions have harmful effects on individuals at risk. Some have even been shown 

to increase the risks of opioid overdose. The causes of these harms often include the sharp reduction of opioid tolerance during periods of high risk 

for relapse; the inadvertent promotion of riskier drug use practices through inattention to structural risk factors; and the exposure of at-risk individuals 

to additional trauma. Examples of strategies shown ineffective by research and data include: arrest and incarceration, compulsory treatment, rapid 

detox without opioid agonist/antagonist medication assistance, inappropriately implemented school-based education (e.g. short sessions focused on 

knowledge improvement and resistance only, mixing students from different risk groups), and inappropriately implemented drug court systems (e.g. low 

quality service provision, improper participant selection, lack of program evaluation).
Evidence-Based Strategies for Preventing Opioid Overdose: What’s Working in the United States, 2018 3

Guiding Principles

Below are four overarching principles, lessons gleaned from previous public health emergencies, such 

as the HIV/AIDS crisis in the 1980s and 1990s. These principles serve as a guide for the design and 

implementation of effective overdose prevention strategies.

1. Know your epidemic, know your response

First advanced by UNAIDS as a guiding principle 

for global HIV prevention and control, the mantra 

“know your epidemic, know your response” 

originally spoke to the mismatch between strategy 

and reality that hindered HIV control efforts in 

the first years of the epidemic. In a 2008 Lancet 

article, Drs. David Wilson and Daniel Halperin 

championed the “know your epidemic, know your 

response” principle with their observation that 

“there is no single HIV Epidemic, but a multitude 

of diverse epidemics” that differ according to “who 

gets infected and how.”2

Similarly, opioid overdose is driven by a multitude of 

mechanisms and human experiences, and people 

may follow a variety of paths toward opioid misuse 

and overdose. The realities faced by people who 

use drugs may be common across regions or vary 

within tight social groups.

“Know your epidemic, know your response” reminds 

us that we must have a clear understanding of the 

causes and characteristics of local public health 

problems before we can know how to tackle them. 

It reminds us that our choices must be driven by 

evidence and data; that we must employ strategies 

we know to be effective; and that we must remain 

vigilant in maintaining a holistic and grounded 

understanding of who is at risk of fatal overdose, 

how that risk is constructed, and what can be done 

to reduce that risk as much as possible.

2. Make collaboration your strategy

Effective solutions to the opioid overdose crisis 

will only emerge from strong partnerships across 

governmental, legal, medical, and other community 

stakeholders. Collaboration between public health 

and public safety is especially important, as the 

impact of illicit opioid use and prescription opioid 

misuse is great on both of these fronts.

Overdose prevention strategies will only be 

successful if the role of each player is well 

designed, reasonable, and clear—and only if 

those players take on those roles in deliberate 

coordination with each other. Accomplishing 

this requires much more than sharing data and 

intelligence. The implementation of a proven public 

health approach such as a 911 Good Samaritan 

Law may be ineffective if law enforcement officers 

are not included in the planning and design of its 

implementation or if public safety protocols at the 

scene of an overdose are not discussed in tandem 

with the law. Similarly, the successful police takedown of a clinician or facility operating as an illegal 

“pill mill” may achieve long-term gains at the 

expense of creating short-term dangers if a public 

health strategy to support the patients suddenly cut 

off from this supply of opioids is not put into place 

ahead of time.

Effectively responding to the opioid overdose crisis 

requires that all partners be at the table and that 

we “make collaboration our strategy” by ensuring 

that all community entities are able to fulfill their 

necessary roles.

3. Nothing about us without us

The phrase “nothing about us without us”3 reflects 

the idea that public policies should not be written 

or put into place (officially or unofficially) without 

the direction and input of the people who will be 

affected by that policy. This mantra has been used 

by persons living with disabilities as they fought for 

recognition as independent persons who know their 

needs better than anyone else.4 It has been used by 

numerous at-risk groups in the U.S. to defend their 

place at the table in the planning of HIV prevention 

strategies.5,6

In the context of today’s opioid overdose epidemic, 

“nothing about us without us” speaks to the fact 

that prevention strategies need to take into account 

the realities, experiences, and perspectives of those 

at risk of overdose. Those affected by opioid use 

and overdose risk should be involved in the design, 

implementation, and evaluation of interventions to 

assure those efforts are responsive to local realities 

and can achieve their desired goals.
4 Centers for Disease Control and Prevention | National Center for Injury Prevention and Control

4. Meet people where they are

Meeting people where they are requires 

understanding their lives and circumstances, what 

objectives are important to them personally, and 

what changes they can realistically make to achieve 

those objectives. For example, abstinence may 

not be immediately achievable by all who use illicit 

substances; however, many smaller changes may be 

feasible and could bring substantial benefit, such as 

reducing the spread of infectious disease, lowering 

overdose risk, and improving overall physical or 

mental health.

The Transtheoretical Model, also called the Stages 

of Change model,7 describes how such behavior 

change often occurs. The model emphasizes the 

need to understand the experience of the person we 

are trying to reach in order to help them. To promote 

change, interventions must be provided that are 

appropriate for the stage in the process that people 

are in.8

The guiding principle of “meeting people where 

they are” means more than showing compassion 

or tolerance to people in crisis. This principle also 

asks us to acknowledge that all people we meet are 

at different stages of behavior change. Furthermore, 

recognition of these stages helps us set reasonable 

expectations for that encounter. For example, a 

person who has experienced an overdose who 

is precontemplative and has not yet recognized 

that their drug use is a problem may be unlikely 

to accept treatment when they are revived, but 

may benefit from clear, objective information about 

problems caused by their drug use and steps they 

can take to mitigate them. Unrealistic expectations 

cause frustration and disappointment for patients, 

providers, family, caregivers, and others touched 

by the event. Someone who is already preparing 

for action, however, may be ready for treatment, 

support, or other positive change. A positive, 

judgement-free encounter with first responders may 

provide the impetus and encouragement needed 

to get started. When we “meet people where they 

are,” we can better support them in their progress 

towards healthy behavior change. Recognizing the 

progress made as a person moves forward through 

the stages of change can help avoid the frustration 

that arises from the expectation that they will 

achieve everything at once.
Evidence-Based Strategies for Preventing Opioid Overdose: What’s Working in the United States, 2018 5

The Transtheoretical Model of Behavior Change

Upward spiral—Learn

fro

m

e

ach

re al p es .

Precontemplation

No intention 

of changing 

behavior.

Contemplation

Aware a problem exists.

No commitment

to action.

Preparation

Intent upon

taking action.

Action

Active 

modification

of behavior.

Maintenance

Sustained change—

new behavior

replaces old.

Relapse

Fall back into

old patterns

of behavior.

This image is adapted from Prochaska & DiClemente, 1983. 

Evidence-Based Strategies
8 Centers for Disease Control and Prevention | National Center for Injury Prevention and Control

Targeted Naloxone Distribution

Naloxone is an opioid antagonist that can quickly and safely reverse the potentially fatal effects of an 

opioid overdose. Targeted distribution programs seek to train and equip individuals who are most likely 

to encounter or witness an overdose—especially people who use drugs and first responders—

with naloxone kits, which they can use in an emergency to save a life. There are many different 

approaches to distributing naloxone to people at high risk of experiencing or witnessing an overdose. 

Effective approaches include community distribution programs, co-prescription of naloxone, and 

equipping first responders.

Why this strategy works

Naloxone is a drug that carries no risk of abuse 

and has no effect on individuals who do not already 

have opioids in their system. It does not generate 

physical dependency. It produces no neurological 

or psychological effects or euphoria. It also poses 

negligible risk of harm if misused. The people who 

most often witness and respond to an overdose 

are other persons who use drugs. By equipping 

these individuals with naloxone and training them to 

identify and respond to an overdose, the potential 

delay between the onset of an opioid overdose 

and the delivery of life-saving care can be reduced 

from hours to seconds. This is especially true in 

rural areas, where residents may experience longer 

EMS response times.9 With powerful opioids, like 

fentanyl and fentanyl analogs, appearing in the 

U.S. drug supply, higher doses of naloxone may be 

needed. Therefore, ready access to naloxone among 

members of the lay community and first responders 

is key for saving lives.

Targeted naloxone distribution programs 

work best when:

n Naloxone is provided to people at high risk of 

experiencing or witnessing overdose.10

n Outreach workers, harm reduction staff, and 

trusted clinicians are properly educated and 

comfortable distributing naloxone to those 

using illicit opioids or receiving a high-risk opioid 

prescription.11

n People who use drugs and first responders are 

well informed as to the potential effects and 

actions of naloxone. Comfort with carrying and 

administering naloxone is crucial.12
Evidence-Based Strategies for Preventing Opioid Overdose: What’s Working in the United States, 2018 9

TRAILBLAZERS

Naloxone has been carried by hospitals and emergency medical services since 

it was approved by the FDA in 1971.

Large-scale naloxone distribution for people who use drugs was first pioneered 

by staff at the Chicago Recovery Alliance in 1996.

In 2003, the DOPE Project in San Francisco began distributing naloxone via 

prescription from Nurse Practitioners working with the project. In 2010, 

California’s standing order for naloxone prescription from the Medical Director 

of the local Department of Health was put in place, allowing the DOPE project to 

more readily distribute naloxone to program participants and expand their reach.

In 2013, Walgreens Pharmacy expanded a pilot naloxone access project in 

Rhode Island, making the overdose-reversing medication available at the 

pharmacy without having to first see a prescriber, thus beginning the first such 

statewide pharmacy-based naloxone program.

Targeted naloxone distribution—What the research says

n 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.13 A similar study carried out 

in Massachusetts found that nearly 90% of 

overdose reversals with naloxone were carried 

out by bystanders who also use drugs.14

n An observational study of a naloxone 

distribution program in British Columbia 

recorded the distribution of 836 naloxone kits 

to people who use drugs and 85 reported 

overdose reversals from among those trained 

and equipped with naloxone by the program, 

indicating that at least one in every ten kits 

distributed had saved a life.15

n An observational study in Ohio found that 

increases in the number of law enforcement 

officers trained and carrying naloxone was 

associated with a reduction in opioid overdose 

deaths and an increase rate of survival 

among opioid overdose victims in the 

surrounding area.16

n A retrospective review of all program enrollee 

information collected by the Massachusetts 

Department of Public Health Overdose 

Education and Naloxone Distribution Program 

found that family members of persons at risk 

of overdose comprised nearly 30% of the 

program’s enrollees and were responsible for 

20% of all recorded rescue attempts. Some 

of those rescues were performed on someone 

other than the relative these participants were 

originally concerned about. These findings 

indicate that naloxone distribution across 

families and social networks can have lifesaving, synergistic effects.17

n An observational study of nearly two thousand 

individuals who had received an opioid 

prescription over a two-year period found that 

those individuals who were co-prescribed 

naloxone along with their opioid analgesic 

prescription had 47% fewer visits to the 

emergency department in the 6 months after 

receiving the prescription and 63% fewer 

emergency department visits after 1 year.18
10 Centers for Disease Control and Prevention | National Center for Injury Prevention and Control

Medication-Assisted Treatment (MAT) 

MAT is a proven pharmacological treatment for opioid use disorder. The backbone of this treatment is 

FDA approved medications. Agonist drugs, methadone and buprenorphine, activate opioid receptors in 

the brain, preventing painful opioid withdrawal symptoms without causing euphoria; naltrexone blocks the 

effects of opioids. MAT is effective at reducing use and helping people to lead normal lives.

Why this strategy works

The World Health Organization has called MAT “one of 

the most effective types of pharmacological therapy of 

opioid dependence.”19 Numerous studies have shown 

that MAT contributes to significant reductions in 

opioid use, criminal activity, overdose, and other risky 

behaviors.20,21 MAT quells cravings and allows patients 

receiving it to stabilize their physical dependency. This 

stability allows MAT patients to achieve healthy social, 

psychological, and lifestyle changes. 

A note about the three FDA-approved medications for 

opioid use disorder:

While all three medications (methadone, 

buprenorphine, and naltrexone) can be effective in the 

treatment of opioid use disorder, decades of research 

support the efficacy of opioid agonist medications 

(methadone and buprenorphine) in preventing 

overdose. We are now learning about the overdose 

prevention capabilities of long-acting, injectable 

naltrexone. Early research indicates that long acting 

naltrexone may share methadone and buprenorphine’s 

overdose prevention effects.22 Though naltrexone has 

also proven effective, research has shown that this 

medication is harder to initiate in some patients23

and that less effective attenuation of withdrawal 

symptoms during the first days of treatment may 

predict treatment drop out.24 Differences in treatment 

response and outcomes with naltrexone are actively 

being researched. Medications, therefore, should be 

selected carefully and tailored to the needs of each 

individual patient.

MAT works best when:

n It is combined with ancillary treatment strategies 

like counseling and social support with fixed, safe, 

and predictable doses of medications.25,26

n Public awareness of MAT as an effective medical 

intervention is promoted by local leadership. 

This helps to reduce stigma against MAT that 

discourages people from seeking this form of 

care.

n Entry into treatment is voluntary. Compulsory 

treatment programs through legal and social 

welfare systems are less effective than voluntary 

treatment.27

n Patients have access to a variety of medication 

options. All patients are different, and treatment 

is best when individualized. Some people fare 

significantly better on buprenorphine than on 

methadone, and vice versa. Some may need to try 

several treatment options before discovering what 

works best, and some may not have access to all 

MAT medications.28

n The challenges of receiving MAT are understood 

and mitigated. Many individuals face hurdles 

in receiving approval for MAT from their health 

insurance provider. Many methadone clinics 

require patients to attend daily to receive 

treatment. This can mean long, burdensome 

commutes at odd hours, which can conflict 

with professional, familial, or care-giving 

responsibilities.29 Those who live in rural areas, 

for example, may have to drive hours to receive 

care. Treatment is more successful when these 

obstacles are not placed in the way.
Evidence-Based Strategies for Preventing Opioid Overdose: What’s Working in the United States, 2018 11

TRAILBLAZERS

Methadone, which originally was synthesized by German scientists in the 

1930s, was first used as a medication for opioid dependency in the 1960s, 

when heroin-related mortality was the leading cause of death for adults 

between 15 and 35 years old in New York City.30

Methadone was approved by the FDA for use in MAT in 1972, followed by 

buprenorphine in 2002. The U.S. Substance Use and Mental Health Services 

Administration (SAMHSA) released guidelines for the clinical management of 

buprenorphine-based MAT in 2004.31

Medication-assisted treatment—What the research says

n A meta-analysis that included eleven different 

studies of methadone as a medication for 

opioid use disorder found that methadone was 

more effective at treating opioid use disorder 

and reducing illicit opioid use than nonpharmacological treatments.20

n A 2014 review of all available evidence on 

buprenorphine as a treatment for opioid use 

disorder found it to be effective in retaining 

patients in care and just as effective as 

methadone in reducing illicit opioid use among 

those retained in care.21

n A longitudinal study that followed MAT patients 

for more than four years found both methadone 

and buprenorphine to be effective long-term 

treatments for opioid use disorder throughout 

that follow-up period.32

n Two studies, one conducted in Australia and 

one conducted in Washington state, have found 

higher death rates among patients receiving 

oral naltrexone compared to patients 

receiving long-acting injectable naltrexone33

or methadone,34 respectively. 

n A meta-analysis concluded that participation 

in pharmacological treatment for opioid use 

disorder, such as MAT, improves HIV treatment 

across the entire continuum of care, increasing 

coverage of antiretroviral treatment by 54%, 

increasing enrollment into antiretroviral 

treatment by 87%, increasing antiretroviral 

treatment adherence by nearly 200%, 

increasing rates of viral suppression by 

45%, and reducing antiretroviral treatment 

discontinuation by 23%.35

n A study that followed MAT patients for a year 

after initiating treatment found that MAT 

patients experienced a significantly improved 

quality of life during the course of their 

treatment.36

n In a clinical trial of more than 300 criminal 

justice-involved individuals with opioid use 

disorder, long-acting injectable naltrexone 

was compared to basic counseling with no 

medication. During the 24-week study period, 

there were no overdose events among the 153 

individuals offered long-acting naltrexone and 

7 overdose events among the 155 individuals 

offered no medication.22
12 Centers for Disease Control and Prevention | National Center for Injury Prevention and Control

Academic Detailing

“Detailing” is a structured educational strategy developed by commercial manufacturers of medical 

and pharmaceutical technologies to market these products to prescribers and pharmacists. “Academic 

detailing” consists of structured visits to healthcare providers by trained professionals who can provide 

tailored training and technical assistance, helping healthcare providers use best practices.

Why this strategy works

The purpose of commercial detailing, the sales 

strategy upon which academic detail is based, is 

the targeted marketing of pharmaceutical products 

to healthcare providers who are best positioned 

to prescribe them, which, depending on state 

law, includes physicians, physician assistants, 

nurse practitioners, and pharmacists. Academic 

detailing takes the most effective practices of 

this commercial marketing and applies them 

to the “marketing” of evidence-based practices 

to healthcare providers and other community 

stakeholders. In the context of overdose prevention 

efforts, academic detailing has been used to assist 

physicians in reducing potentially risky opioid 

prescribing practices, to prepare pharmacists 

to effectively distribute naloxone to the public, 

and many other innovative and community-based 

initiatives designed to deliver new skills to those 

individuals poised to make an impact on the rate of 

overdose in their communities.

Academic detailing works best when:

n Dedicated and trained detailing teams are 

deployed for all academic detailing activities, 

as this strengthens the detailing approach and 

fosters consistency within the project.37

n The individuals who receive academic detailing 

possess the means and resources to put their 

newly gained knowledge to use. For instance, 

physicians who treat patients receiving opioid 

medications often benefit from additional staff 

support, as evidence based opioid prescribing 

requires additional patient follow-up activities 

and administrative tasks.38 
Evidence-Based Strategies for Preventing Opioid Overdose: What’s Working in the United States, 2018 13

TRAILBLAZERS

Since 2013, the New York City Department of Health and Mental Hygiene, in 

collaboration with the U.S. Centers for Disease Control and Prevention (CDC), has 

actively undertaken two academic detailing campaigns: one to support providers 

of buprenorphine-based MAT with additional training and assistance, and the 

other to train and support clinic staff in adopting safe opioid prescribing practices.

The San Francisco Department of Public Health recently sponsored the CIAO 

(California Intervention for Academic Detailing on Opioids) study, which supported 

rural counties in developing and implementing academic detailing for primary 

care providers on safe opioid prescribing, overdose prevention, and 

buprenorphine-based MAT.

The Veterans Health Administration has made academic detailing a key 

component of its national Opioid Overdose Education and Naloxone 

Distribution program.

Academic detailing—What the research says

n A recent review found that commercial detailing 

is so effective in prompting behavior change 

among healthcare providers that its effects 

are overpowering those of traditional academic 

information sources. One major factor behind 

this pattern is that researchers who produce 

and seek to disseminate scientific medical 

knowledge are rarely trained in effective 

communication strategies. Academic detailing 

corrects this disparity by “marketing” new 

science to healthcare providers in a compelling 

and efficacious manner.39

n Academic detailing has been used to improve 

physician practices across a variety of medical 

spheres, including opioid prescribing,40 proper 

medication dosing for patients with limited renal 

function,41 and the timely screening of pregnant 

women for high-risk infections.42

n In a recent study on the effects of academic 

detailing on general practitioners, those who 

received detailing significantly improved their 

clinical management of refractory labored 

breathing. Further, more than 80% of those 

physicians who did not receive detailing lacked 

confidence in their knowledge of and ability to 

manage this condition.43

n A 2013 overdose prevention intervention carried 

out on Staten Island used targeted educational 

sessions with medical providers to reduce rates 

of inappropriate opioid prescribing and overdose 

death. The intervention resulted in a 29% 

decrease in prescription opioid overdoses on 

Staten Island, even as overdose rates remained 

unchanged in New York City’s other boroughs.44

n Recent efforts to increase the rate of naloxone 

prescription by general practitioners through 

academic detailing have shown remarkable 

results. A study in San Francisco found an 

eleven-fold increase in the rate of naloxone 

prescription among physicians who received 

a half-hour-long academic detailing session.45

Further, a large scale academic detailing effort 

in the Veterans Health Administration was able 

to reach more than 7,000 physicians in less 

than a year.46 This effort resulted in a threefold increase in naloxone prescription one year 

after the intervention and a seven-fold increase 

two years later, indicating that physicians 

were enabled to improve their clinical practice 

independently even after the academic detailing 

had taken place.47
14 Centers for Disease Control and Prevention | National Center for Injury Prevention and Control

Eliminating Prior-Authorization Requirements 

for Medications for Opioid Use Disorder

In this scenario, health insurance providers cover the cost of MAT as a standard benefit and all 

requirements that a physician contact the insurance provider for approval prior to writing the 

prescription (a process called “prior authorization”) are removed. Without these prior authorization 

requirements, prescriptions for MAT medications to treat opioid use disorder can be written and filled as 

soon as a physician deems this treatment necessary, free from artificial delays.

Why this strategy works

Prior authorizations may take up to several days to 

process with insurance providers. This processing 

time creates an immediate barrier to a patient’s 

initiation onto treatment. This delay forces patients 

to leave their provider’s office without receiving 

potentially life-saving medication, only to return 

again to receive it several days later. During that 

time, treatment can be derailed. A patient may 

lose interest, lose access to their doctor, lose 

transportation, suffer an injury, or even die from an 

overdose.

The removal of prior authorization requirements 

allows a patient to be initiated onto treatment the 

same day they see their doctor. This immediate 

initiation reduces the patient’s risk of overdose in 

the subsequent days and increases the likelihood 

that they will successfully engage in and remain 

connected to treatment.

Due to regulations governing the provision of 

methadone, buprenorphine and naltrexone are 

the only FDA-approved medications for opioid use 

disorder potentially subject to prior authorization 

requirements. 

Removing prior authorization 

requirements works best when:

n Policy makers and healthcare providers work 

collaboratively with health insurance companies 

and state Medicaid programs to design and 

implement these policy changes.48
Evidence-Based Strategies for Preventing Opioid Overdose: What’s Working in the United States, 2018 15

TRAILBLAZERS

In 2016, an investigation of barriers to treatment for opioid use disorder 

in New York prompted Cigna to voluntarily remove all prior authorization 

requirements for policy holders seeking prescription buprenorphine. Anthem 

Inc. also removed these requirements a few months later.

In March 2017, Aetna removed all prior authorization requirements for its 

private insurance plans.

In Rhode Island, the Governor’s Overdose Prevention Task Force brought 

insurance company representatives to the table to help coordinate 

statewide overdose reduction measures. Following these collaboration 

efforts, Neighborhood Health Plan of Rhode Island and United Healthcare, 

the state’s two Medicaid managed care providers, along with Blue Cross 

Blue Shield and Tufts Health Plan, two private health insurance providers, 

removed prior authorization for prescription buprenorphine for all of their 

policyholders to better support the state’s overdose prevention efforts.

Eliminating prior-authorization requirements for medications for opioid use disorder—

What the research says

n In 2014, prior authorization for prescription 

buprenorphine was still required for 35% of 

Health Maintenance Organizations (HMOs), 

36% of Preferred Provider Organizations 

(PPOs), and more than half of Consumer 

Driven Products (CDPs).49

n Self-treatment with diverted (i.e. misused) 

opioid medications is common among 

individuals with opioid use disorder who have 

recently experienced barriers to or delays in 

starting buprenorphine-based MAT.50,51,52
16 Centers for Disease Control and Prevention | National Center for Injury Prevention and Control

Screening for Fentanyl in Routine Clinical Toxicology Testing

The standard panel of substances included in routine clinical drug screens (carried out in hospitals, 

clinics, treatment centers, etc.) should include screening for fentanyl exposure, particularly in 

jurisdictions where fentanyl is known to be prevalent in the local illicit drug market.

Why this strategy works

Because it is such a highly potent and fast acting 

opioid, and because it is often difficult—if not 

impossible—to identify prior to consumption, the 

presence of fentanyl in illicit drug supplies changes 

the landscape of opioid overdose dramatically. 

Harm reduction, risk reduction, and opioid overdose 

prevention efforts all need to be informed by an 

awareness of fentanyl exposure in the populations 

served in order to continue affording maximum 

safety and protection to community members who 

are navigating a fentanyl-contaminated drug supply.

The addition of fentanyl testing in routine clinical 

toxicology tests allows for early warnings of supply 

contamination and provides one of the best sources 

of routine surveillance for fentanyl in the local drug 

supply. The results of fentanyl screens may also 

have implications for the clinical management 

of substance use disorder for fentanyl-exposed 

individuals and for public health responses to opioid 

use and overdose.

Fentanyl testing in routine drug screens 

works best when:

n Adjustments are made to funding streams, 

standard lab procedures, and electronic 

medical records systems to accommodate and 

standardize this change in practice.53,54

n Trends in the results of fentanyl screens are 

shared effectively across public institutions with 

the capacity to intervene amongst those who 

intentionally or unintentionally consume fentanyl 

and reduce the risk of overdose.55
Evidence-Based Strategies for Preventing Opioid Overdose: What’s Working in the United States, 2018 17

TRAILBLAZERS

In 2017, Lifespan, the parent company of the largest hospital network in 

Rhode Island, instituted a new policy mandating that fentanyl be added to 

the panel of drugs screened for among patients who are in the emergency 

department following an overdose. This practice ultimately became part 

of the state’s Standard of Care for the Treatment of Opioid Addiction and 

Overdose in Emergency Departments and Hospitals.

Some outpatient methadone-based MAT programs have also begun 

testing for fentanyl in all urine screens, identifying individuals who were 

struggling in treatment and may not have known they were at risk of 

fentanyl-related overdose.56

Screening for fentanyl in routine clinical toxicology testing—What the research says

n A study conducted in Vancouver, British 

Columbia, that tested urine samples from 

242 people who inject drugs found that 29% 

of all participants (only 59% of whom reported 

using heroin) tested positive for fentanyl. Of 

those who tested positive for fentanyl, nearly 

75% did not report using fentanyl in the past 

three days, indicating that they were not aware 

they had been exposed. The same study 

also found that people who reported using 

methamphetamine had 6-times the odds of 

testing positive for fentanyl, compared to those 

who did not report using methamphetamine. 

At the time, this was a counter-intuitive finding, 

which would have likely not been discovered 

without adding fentanyl screening to these drug 

testing procedures.55

n A recent study conducted in the Detroit area 

found that 38% of clients receiving methadonebased MAT tested positive for fentanyl in 

standard monthly drug screenings at least once 

between January 2015 and May 2016. Clients 

who tested positive for cocaine were more likely 

to test positive for fentanyl as well.57

n Data collected from more than 700 medical 

records at a methadone-based MAT clinic in 

Rhode Island revealed that approximately one 

in seven methadone patients tests positive for 

fentanyl each month, and nearly two-thirds of 

new patients initiating methadone-based MAT 

tested positive for fentanyl at intake.56 Each of 

these factors may shape a patient’s experience 

of treatment and individual needs while 

receiving care.
18 Centers for Disease Control and Prevention | National Center for Injury Prevention and Control

911 Good Samaritan Laws

The term “911 Good Samaritan Law” refers to local or state legislation that may provide overdose 

victims and/or overdose bystanders with limited immunity from drug-related criminal charges and other 

criminal or judicial consequences that may otherwise result from calling first responders to the scene. 

The scope of 911 Good Samaritan Laws varies across U.S. states, but each is written with the goal of 

reducing barriers to calling 911 in the event of an overdose.

Why this strategy works

Frequently, individuals who witness an overdose 

have been using opioids themselves. Calling 911 

for an overdose victim is an inherently risky thing for 

such bystanders to do. Emergency medical services 

are often accompanied by the police, and police 

have the discretion to execute warrants, search the 

premises, and arrest bystanders for drug-related 

charges that are coincidental to the overdose 

emergency at hand. When facing the risk of arrest, 

detention, prosecution, and potentially prison time, 

bystanders are forced to weigh their own wellbeing 

against the wellbeing of the person who is in crisis 

in front of them.

By providing limited immunity from drug charges 

arising from evidence found at the scene of an 

overdose, 911 Good Samaritan Laws defuse this 

conflict, allowing a bystander to seek emergency 

care for an overdose victim without putting 

themselves at risk of arrest.

Good Samaritan Laws are most

effective when:

n Immunity is extended to all bystanders on the 

scene, not only to the individual in crisis and the 

individual who called 911.58

n Bystanders are protected from parole violations 

and warrant searches in addition to receiving 

immunity from criminal charges. Any perceived 

risk to the freedom or safety of the bystander 

reduces the probability that 911 will be 

called.58,59

n Police officers and other first responders 

are well informed as to their liabilities and 

responsibilities when responding to an overdose 

as outlined in their state’s 911 Good Samaritan 

Law and other state and local regulations.

n People who use drugs are well informed 

about the 911 Good Samaritan law and have 

reason to trust that those protections will be 

consistently afforded to them when they 

call 911.60

n The hospital experiences of people who 

use drugs are strengthened and improved. 

Individuals in crisis will not call for emergency 

care if they don’t want to be transported to the 

hospital due to previous maltreatment.61
Evidence-Based Strategies for Preventing Opioid Overdose: What’s Working in the United States, 2018 19

TRAILBLAZERS

In 2007, New Mexico became the first state to pass a 911 Good Samaritan 

Law for overdose prevention—extending immunity from criminal liability for 

drug possession to victims of an overdose crisis and for those who seek help.

As of May 2018, all but five states have enacted similar legislation.

911 Good Samaritan Laws—What the research says

n A large study of overdose scenarios in 

Baltimore found that 911 was called during 

only one in five overdoses witnessed, and that 

the presence of more than four bystanders 

statistically decreased the probability that 911 

would be called.58

n An evaluation of 911 Good Samaritan Law 

education efforts in New York City found that 

awareness of this law statistically increased the 

likelihood that a bystander would call 911 in the 

event of an overdose. This finding was true for 

all participants across race, age, and gender.60

n Multiple studies in the U.S. and Canada have 

observed that bystanders of an overdose are 

concerned that they will be arrested or have 

negative police interactions if 911 is called, 

which effectively deters many bystanders from 

making the call.62,63

n A large study of opioid using parolees in 

Alabama found that a number of bystanders 

(about 30%) will try to find help through means 

other than calling 911, such as dropping off 

the overdose victim at a hospital. Though it may 

be done with good intentions, this response 

could mean a fatal delay in care for the 

overdose victim.64

n Many police officers, when first introduced to the 

idea of 911 Good Samaritan Laws, experience 

concern about jurisdictional issues and liability 

surrounding the carry and administration of 

naloxone.65 However, simple trainings and 

informational tools have been shown to quickly 

increase police officer familiarity and comfort 

with overdose response.61

n Young adults who report using opioids in 

Rhode Island have poor awareness of the 

local Good Samaritan law, indicating that 

targeted awareness raising may be needed for 

these laws to be effective across the entire 

community.66
20 Centers for Disease Control and Prevention | National Center for Injury Prevention and Control

Naloxone Distribution in Treatment Centers 

and Criminal Justice Settings

Naloxone distribution programs in criminal justice and treatment facilities (both inpatient and 

outpatient) target individuals who are about to be released from supervision and/or cease treatment to 

receive overdose response training and naloxone kits prior to their exit from the program or facility.

Why this strategy works

Individuals with a history of incarceration are, 

in general, at higher risk of overdose. Periods 

immediately following release from supervision or 

treatment, when a person’s opioid tolerance is low, 

are especially dangerous: an individual is more than 

twenty-five-times more likely to overdose in the first 

weeks following the cessation of treatment than 

during treatment,67 and release from incarceration, 

also defined by abrupt reintegration in the context 

of lowered opioid tolerance, places individuals 

with opioid dependency at similar risk.68 Naloxone 

distribution programs operated within treatment 

and correctional settings are an effective way to 

train and equip this extremely high-risk group—

as well as their friends and family members—with 

life-saving naloxone.

Naloxone distribution in treatment

centers and criminal justice settings

works best when:

n Coverage of these distribution programs is 

universal, providing all individuals leaving 

criminal justice settings or treatment with the 

opportunity to be trained and receive a naloxone 

kit. This is preferable to opt-in programs that 

require inmates to request special services to 

receive naloxone.69

n Training is provided in a way that refrains from 

making negative judgments about drug use 

and focuses instead on the importance of 

every person’s safety and wellbeing even in the 

context of drug use.70

n Close contacts of the individual (family, 

partners, and children) are also trained 

in naloxone administration and overdose 

response.10

n Naloxone distribution in treatment centers and 

criminal justice settings works best when there 

is certainty in the supply chain and in funding. 

In treatment settings, an individual’s insurance 

can cover the cost of naloxone.71
Evidence-Based Strategies for Preventing Opioid Overdose: What’s Working in the United States, 2018 21

TRAILBLAZERS

The first pilot programs for overdose prevention for incarcerated individuals 

took place in jails in Pittsburg and New York City, where naloxone was provided 

to incarcerated persons upon release or to caregivers visiting the detainees.

Since 2005, Rhode Island’s adult prison system has trained inmates on 

overdose prevention. The prison then began providing naloxone to inmates at 

release in 2010, a model that other states have since adopted.

Baltimore area jails began distributing naloxone to at-risk individuals in 2016, 

following a recommendation from Maryland’s Heroin and Opioid Emergency 

Task Force.

Naloxone distribution in treatment centers and criminal justice settings—

What the research says

n A nationwide study of more than 10,000 

individuals exiting specialized drug treatment 

settings in the U.S. found that rates of overdose 

death were twenty-six times higher in the first 

month following the cessation of treatment 

compared to the rate of overdose death while 

individuals were in treatment.67

n A similar study of more than 5,000 individuals 

ceasing outpatient MAT for substance use 

disorder found that overdose death rates were 

nine times higher than baseline in the first two 

weeks following treatment cessation, eight 

times higher in weeks three and four following 

treatment cessation, and approximately 

1.9 times higher in the second month.72

n A large meta-analysis of data from several 

different nations found that individuals released 

from incarceration experience a three to eightfold increase in the rate of overdose death in 

the first two weeks after release compared to 

weeks three through twelve following release.73

n A study carried out by the Massachusetts 

Department of Public Health found that 

individuals recently released from incarceration 

in the Commonwealth are 56 times more likely 

to overdose than members of the general 

public, indicating urgent need to scale up 

overdose prevention services for this population 

both before and after release.74

n Scotland’s National Naloxone Programme, which 

started providing naloxone at release to inmates 

in 2011, was associated with a 36% reduction 

in the proportion of opioid- related deaths that 

occurred within the first four weeks following an 

individual’s release from prison.75
22 Centers for Disease Control and Prevention | National Center for Injury Prevention and Control

MAT in Criminal Justice Settings 

and Upon Release

In this intervention, MAT should be made available as a standard of care for incarcerated individuals 

with opioid use disorder. Those receiving MAT when they enter a criminal justice setting may continue 

receiving this treatment, and those who are not on treatment may initiate and continue this form of care 

while incarcerated and then be linked with appropriate care providers to continue MAT upon release.*

Why this strategy works

MAT is one of the most effective forms of treatment 

available for opioid use disorders. MAT has been 

shown to lower rates of illicit drug use, lower risk 

of overdose, lower rates of drug-related crime, and 

increase engagement with many other essential 

forms of healthcare.

Providing MAT in jails and prisons not only brings 

healthcare in correctional facilities in line with 

current medical standards for the treatment of this 

medical disorder, it also improves the likelihood 

that incarcerated persons will engage in care in the 

future and lowers the likelihood of relapse, problem 

opioid use, and risky opioid use after release.

MAT in criminal justice settings works

best when:

n MAT is uninterrupted for those who were 

receiving care prior to incarceration.76

n MAT can be initiated in criminal justice 

settings.69

n Individuals have access to all available forms 

of MAT medication. This choice is essential, as 

some individuals fare much better (or worse) on 

one of these drugs than on the other.28

n An effective system for referral and linkage 

to care is in place so that individuals on MAT 

can receive a “warm handoff” to providers who 

are able to continue their care upon release.77

Otherwise, recently released individuals are 

forced to choose between enduring painful 

opioid withdrawal and quickly finding another 

source of opioids. The quickest and easiest 

sources of opioids are illicit ones.

*Medicare and Medicaid generally do not pay for services rendered to individuals in custodial settings. Applicable statutory and/or regulatory exclusions 

will apply.
Evidence-Based Strategies for Preventing Opioid Overdose: What’s Working in the United States, 2018 23

TRAILBLAZERS

Rikers Island Correctional Facility, New York City’s jail, has been offering MAT 

with opioid agonist medication to inmates since 1987. Today, the facility 

provides both methadone and buprenorphine.

Vermont began piloting MAT care with methadone and buprenorphine at two of 

its jails in 2014.

In 2016, Rhode Island became the first state to implement a program offering 

buprenorphine, methadone, or naltrexone to all incarcerated persons (in jail or 

in prison) with substance use disorder, both maintaining those who became 

incarcerated and initiating many into MAT care for the first time.

MAT in criminal justice settings and upon release—What the research says

n Multiple studies have found that MAT in 

correctional facilities is associated with 

decreased heroin use, decreased levels of 

syringe sharing, decreased criminal activity, and 

a significantly higher probability of engaging with 

treatment upon release.78–81

n A study conducted among nearly 300 

incarcerated persons in Rhode Island concluded 

that forced withdrawal from methadone upon 

incarceration (among those who were receiving 

methadone prior to incarceration) reduces 

the likelihood that an individual will engage 

in care after release.82 Forced withdrawal is 

required in correctional facilities where MAT is 

not available. 

n A study conducted at Rikers Island found that 

individuals given buprenorphine-based MAT 

during a 10–90-day incarceration were more 

likely than those given methadone-based MAT to 

continue treatment after release.83

n A Baltimore study found that incarcerated 

individuals who received methadone stayed in 

treatment for an average of 166 days in the 

year following their release, whereas those who 

received only counseling but no MAT engaged 

in treatment for an average of 23 days following 

release and were more likely to test positive for 

opioids at 12 months after release.84

n Within one year of initiating its new MAT 

program in all state adult correctional 

facilities, the state of Rhode Island observed 

a 60% decrease in the proportion of recently 

incarcerated individuals who suffered a fatal 

overdose. The state also observed a 12% 

overall decrease in overdose fatalities 

compared to the previous year, which can 

be attributed to the deaths prevented by the 

prison’s MAT program.85
24 Centers for Disease Control and Prevention | National Center for Injury Prevention and Control

Initiating Buprenorphine-based MAT 

in Emergency Departments

Patients receiving care in emergency departments who have untreated opioid use disorder are referred 

to a provider for long-term buprenorphine-based MAT. This referral is accompanied by initial doses of 

buprenorphine or a short-term prescription that can be filled right away. The patient can begin treatment 

immediately, instead of waiting several days for their appointment with a new provider.

Why this strategy works

Even if a patient in the emergency department 

is very eager to begin MAT, receiving a referral 

and possibly waiting several days to begin care 

greatly decreases the likelihood that this patient 

will successfully engage in care. Providing an 

initial dose of buprenorphine in the emergency 

department eliminates these delays in care and 

allows the patient to begin experiencing the benefits 

of MAT immediately. Subsequent daily doses 

provided by the hospital (either by prescription or by 

supervised consumption at the hospital pharmacy) 

serve as a “bridge,” providing the patient with 

care on a temporary basis, if necessary, while a 

referral and “warm hand off” to a physician who can 

continue to provide MAT is carried out.

Initiating buprenorphine-based MAT 

in emergency departments works 

best when:

There is no broadly accepted “best practice” for 

initiating patients onto buprenorphine-based MAT 

in an emergency department. This intervention is 

very new, and researchers are still studying how 

best to serve patients’ needs and assist them in 

engaging with care. Patients who are initiated in 

the emergency department are very likely there 

because they have experienced an overdose 

crisis. It can be expected that such an experience 

may change the meaning of treatment for these 

patients, and the value of treatment may change in 

an inconsistent or counter-intuitive way over time.

What we do know, however, is that each instance of 

engagement in MAT, even if the patient eventually 

drops out of care, predicts higher success the 

next time treatment is sought. Furthermore, 

providing “bridging” doses of MAT medications 

to individuals seeking treatment greatly improves 

patient engagement in MAT care during treatment 

initiation—a key moment for those with opioid use 

disorder, when maintaining trust and stability is of 

utmost importance.86,87
Evidence-Based Strategies for Preventing Opioid Overdose: What’s Working in the United States, 2018 25

TRAILBLAZERS

Yale University Hospital in New Haven, Connecticut, was the first institution 

to begin initiating MAT in their emergency department in 2015. They found 

that patients who started MAT in the emergency department were twice as 

likely to be in engaged in treatment 30 days after discharge.

Boston Medical Center operates the Faster Paths to Treatment program in 

a similar way. The program also initiates patients with opioid use disorder 

hospitalized for other conditions and people in residential treatment 

programs in the community who request or would benefit from MAT. Patients 

are immediately stabilized on buprenorphine or connected to a methadone 

program and then actively transitioned to a primary care provider or other 

provider of long-term care. Patient navigators assist patients in connecting 

with and continuing care.

Initiating buprenorphine-based MAT in emergency departments—What the 

research says

n A 2010 study conducted in a location with 

very long wait lists (6 months or more) for MAT 

provided those who were seeking treatment 

through a personal physician or a licensed 

opioid treatment program with immediate 

access to buprenorphine via prescription while 

they waited for a slot in a formal treatment 

program. Compared to those who were not 

offered this medication immediately, these 

individuals reported significant reductions in 

illicit opioid use, opioid withdrawal symptoms, 

and opioid cravings, even before they began 

wrap-around treatment. The medication 

adherence rate was 99%, indicating almost 

no medication diversion.86,87

n Yale University Hospital conducted a 

randomized controlled trial to test the effect 

of initiating patients on buprenorphine in the 

emergency department and then continuing that 

MAT in primary care. Two months later, those 

patients who received buprenorphine prior to a 

referral for MAT were more likely to be engaged 

in care and had lower rates of illicit opioid 

use. Six months later, the study’s findings 

were less encouraging, which indicates that 

patients initiated onto MAT in the emergency 

department may need additional supports to 

remain engaged in care.88 The hospital now 

employs patient navigators and counselors 

to support patients who may be struggling to 

maintain their treatment.
26 Centers for Disease Control and Prevention | National Center for Injury Prevention and Control

Syringe Services Programs

Sometimes called “needle exchange” or “syringe exchange,” syringe services programs provide access to 

clean and sterile equipment used for the preparation and consumption of drugs as well as tools for the 

prevention and reversal of opioid overdose, such as naloxone training and distribution, fentanyl testing 

strips, and more. Comprehensive syringe services programs also provide additional social and medical 

services such as: safe disposal of syringes and needles; testing for HIV and hepatitis C infection and 

linkage to treatment; education about overdose and safer injection practices; referral and access to drug 

treatment programs, including MAT; tools to prevent HIV and other infectious disease, such as condoms, 

counseling, or vaccinations; and linkage to medical, mental health, and social services.

Why this strategy works

Syringe services programs are a key component 

of overdose prevention strategies, because they 

can facilitate access to and uptake of services 

and interventions for reducing overdose, enhancing 

health and wellbeing, and improving public health 

and public safety.

First, some, but not all, people who use drugs 

experience homelessness, poverty, and other social 

or financial insecurities that make acquiring clean 

injection equipment challenging, even in locations 

where syringes can be purchased without a 

prescription. The free distribution of clean injection 

equipment lowers the frequency of syringe sharing 

and re-use,89–91 with major protective impacts on the 

rates of infectious diseases like HIV and hepatitis 

C as well as other injection-related infections or 

soft tissue injury.92,93 Individuals who participate in 

syringe services programs are also more likely to 

seek treatment for a substance use disorder.94

Second, syringe services programs provide people 

who use drugs a non-judgmental environment in 

which they are able to build supportive and trusting 

relationships, talk freely about their needs and 

concerns, and re-enforce feelings of self-worth, 

empowerment, and control. Relief from the shame 

and judgment carried by the stigma associated 

with drug use gives people the freedom to think 

objectively about the risks their drug use may 

pose to themselves and others and to strategize 

steps they can take to mitigate those risks. For 

people who are socially marginalized and have 

internalized stigma about their drug use, these 

services can substantially benefit their safety and 

chances of survival.

Third, if and when someone who uses drugs 

chooses to seek medical care, naloxone access, 

or substance abuse treatment, syringe services 

programs and their staff are able to help their 

participants connect with and navigate these 

services, making syringe services programs a 

key component of overdose prevention efforts on 

all fronts.
Evidence-Based Strategies for Preventing Opioid Overdose: What’s Working in the United States, 2018 27

Syringe services programs work best when:

n They provide an adequate supply of sterile 

syringes. Limiting the number of syringes an 

individual may receive reduces the effectiveness 

of the intervention. Programs with one-forone exchange policies, for example, allow 

participants only as many syringes as the 

number of used syringes they return, thus 

undercutting the program’s own effectiveness.95

When no limits are set on the number of 

syringes distributed, participants are more 

likely to have clean syringes on hand when they 

need them, and they can provide syringes to 

many more people than can attend the program 

themselves, thus multiplying the program’s 

effectiveness. This also increases participants’ 

incentive to visit the program and interact with 

staff and counselors.96

n The needs and concerns specific to the local 

drug using community are addressed and 

accommodated by the program.97

n Program participants who are seeking treatment 

for opioid use disorder or for other physical or 

mental health concerns are offered assistance 

in accessing appropriate care.98,99

Syringe services programs—What the research says

n Syringe services program participants are five 

times more likely to enter drug treatment and 

3.5 times more likely to cease injecting 

compared to those who don’t utilize these 

programs.100

n Syringe services programs are more effective 

at preventing disease and maximizing service 

coverage when distribution rules are less 

restrictive, such as when the program is 

distribution-based, not exchange-based, and 

when distribution limits are high.95,101

n A key element to the success of syringe service 

programs in reducing disease and overdose 

and in connecting more participants with care 

is the refocusing of public responses to drug 

use away from criminal justice approaches, 

which discourage safer drug use behaviors and 

requests for help, to public health approaches 

focused on the underlying drivers of these 

risks.102 Law enforcement officials can play 

an important role as partners in this shift by 

directing people found using illicit drugs to 

treatment programs rather than arresting and 

detaining them.

n A recent study found that individuals who use 

drugs who were recently incarcerated are at 

significantly higher risk of overdose and are 

more willing than their non-incarcerated peers 

to receive training for and administer naloxone 

when this is offered by a syringe services 

program, making syringe service programs a 

particularly important intervention for assisting 

these high-risk individuals.103

n Some regions have begun implementing syringe 

access and disposal services at pharmacies 

and have achieved success in decreasing 

syringe sharing and reuse.104 However, a study 

in San Francisco found that more than 65% of 

interviewees who used drugs regularly disposed 

of syringes at syringe service programs, 

and almost none disposed of syringes at 

pharmacies, indicating that pharmacies alone 

cannot fill the role played by these programs 

with respect to syringe disposal.105
28 Centers for Disease Control and Prevention | National Center for Injury Prevention and Control

TRAILBLAZERS

The concept of syringe access was borne from local efforts to prevent 

hepatitis B in the 1980s in Rotterdam, Holland.

In the 1990s, the U.S. government funded several studies that demonstrated the 

effectiveness of syringe services programs, leading then-Secretary of HHS Donna 

Shalala and NIDA Director Nora Volkow to herald the efficacy of 

these programs.

By 2014, syringe services programs were operating in nearly 200 U.S. cities.

In 2015, Congress lifted a ban on federal funding for syringe services programs, 

allowing federal funds to be used to support syringe service programs and the 

wrap-around services that are a part of the program; however, federal funds 

cannot be used to purchase the actual syringes distributed.106

In 2015, Kentucky opened numerous syringe service programs across the 

state. These programs offer all participants referrals to drug treatment, case 

management, HIV and hepatitis C testing and referral to treatment, syringe 

access, and safe syringe disposal services. In the first six months of operation, 

these programs served more than 1400 unique individuals and distributed more 

than 128,000 clean syringes. A similar syringe service program run by the CabellHuntington Health Department in West Virginia helped reduce the proportion of 

their clients sharing syringes from above 25% to below 10% between September 

2015 and March 2016.

The People’s Harm Reduction Alliance, a community organization that provides 

syringe services to communities across western Washington and northern 

Oregon, employs a variety of methods for reaching individuals in need of services 

including stationary or “brick and mortar” locations and supply delivery on 

demand by car, by bike, or on foot. Since 2007, the organization has distributed 

more than 10,000 naloxone kits and has recorded more than 5,000 overdose 

reversals based on client reports.
Evidence-Based Strategies for Preventing Opioid Overdose: What’s Working in the United States, 2018 29

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