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Winograd came to MO-HOPE with more than 10 years of experience using harm reduction strategies to reduce high-risk alcohol use; her previous position focused directly on creating a naloxone distribution program to address opiate misuse. Harm reduction strategies can be controversial because the focus is not on encouraging abstinence, but instead on reducing or mitigating the adverse behaviors or consequences associated with substance misuse. Winograd’s “practical experience” doing this work helped her anticipate many of the barriers the team was likely to encounter. For example, she understood and could speak directly to the reluctance of many state-level government officials to adopt a prevention strategy—such as naloxone distribution—that was shown to be effective in preventing death from overdose, but which might also be construed as enabling continued substance misuse. Her experience also prepared her to build a foundation of support for MO-HOPE, another key role she plays: “I do a lot of work around capacity building, specifically getting buy-in with folks at various institutions and making sure we have the clinical support for implementation.”

Winograd is quick to establish that any knowledge she brought to the project was the result of years of working with talented researchers and practitioners. ”I learned what works from “the real experts,“ she says. “There are researchers and clinicians who have been utilizing these life-saving interventions, largely underground and outside of the mainstream, for decades.” Winograd’s role, as she explains it, was to pass along their collective expertise. Her skills in dismantling barriers, building capacity, and drawing on expert knowledge successfully set the stage for MO-HOPE’s quick implementation and rapid expansion.

Don’t Start from Scratch (If You Don’t Have To)

Winograd sought out existing training programs to use a model for MO-HOPE’s training. “I came from the St. Louis Veterans Administration,” she explains. In working with their Opioid Overdose Education and Naloxone Distribution (OEND) program, she learned which educational tactics worked with which audiences, and used much of the VA’s program as a model, subsequently modifying it to meet the needs of MO-HOPE’s specific audiences. Winograd acknowledges that she chose the VA program based on her own experience, but stresses that there are plenty of others she could have chosen from. “There’s no reason to reinvent the wheel,” she says. “With more people dying from opioid overdose every day, we’d rather spend our time training people to save lives.”

Prepare for a Learning Curve

According to Winograd, Missouri is a state without a history of using harm reduction to address substance misuse. “Most people here use primary prevention—that is, strategies to prevent people from misusing in the first place. Naloxone is not that. So there has been a learning curve, for sure,” Winograd explains. “The PDO grant came at the perfect time for Missouri.” Because of the grant, the MO-HOPE team has been able to substantiate naloxone as a safe and effective strategy for addressing Missouri’s opioid epidemic. “The SAMHSA grant normalized the use of naloxone. It communicates the message that, if the federal government is funding this, it’s not a crazy, radical thing. We can now put naloxone on the main stage in prevention and treatment discussions,” Having the ability to offer free services that are supported by grant funding has also been another way to bring agencies to the table. Explains Winograd, “Once word got around that we offer these trainings and free naloxone, there’s been a huge demand.”

Acknowledge Where Partners are Coming From

Winograd speaks insightfully about the importance of acknowledging and addressing specific partner concerns as critical piece of obtaining buy-in. “Presenting evidence is important, but it’s not always the place to start.” For example, when she first started the project, law enforcement personnel were not engaged with statistics about naloxone efficacy, but rather were concerned that giving people naloxone would result in more and/or riskier use. “There was concern about the message we were sending, that we were enabling users or somehow saying that opioid use was ok. Officers also struggled with the unfairness of helping those who routinely cause negative consequences due to their addiction, like crime and child neglect.” Winograd recognizes the importance of acknowledging these concerns, but of also re-framing the narrative to focus on the nature of addiction as a chronic disease and the benefits of the intervention. “We explained that people can’t recover if they are dead; they can’t get into treatment. We are giving people a second chance at life and recovery—and often a third or a fourth or a fifth chance, as well,” Winograd explains.

Reduce Anxiety

MO-HOPE trains people on how to administer naloxone, which Winograd explains was an intentional decision. For law enforcement, in particular, “many officers had fears about ‘messing up’ [when administering the medication] and harming the people they were treating.” To address this fear, trainers spend time helping participants understand the pharmacology of the medication, highlighting, in particular, that naloxone can’t be over-administered. “It’s a relief to the officers to know that they can’t give too much of the drug and that it has no effect if a person hasn’t overdosed on opiates,” Winograd explains.

Be Willing to Compromise

When MO-HOPE began training law enforcement personnel, they realized they would need to be flexible about their approach. “Officers are around overdoses a lot. They had strong concerns around reversing overdoses and then being forced to deal with people who can be extremely angry once they realize what has happened,” Winograd explains. In one MO-HOPE training to a St. Louis police district, a captain suggested that officers handcuff people prior to administering naloxone. The MO-HOPE team was resistant but was not in a position to mandate their protocol. “They are the ones out there doing this work. They don’t want to do this in the first place. So if they have some ideas for how to protect their safety—like handcuffing people before giving naloxone—and that’s what needs to happen for them to revive them, then we’d rather them do that than not have them use it all,” she says. This flexibility has extended to MO-HOPE’s work with treatment providers, some of whom are comfortable handing out naloxone to their opioid-using clients and others who are not. “We have to meet people where they are,” Winograd says. “Not everyone is ready at the same time.”

Evaluate! Evaluate! Evaluate!

Since their first trainings, the MO-HOPE team has taken careful notes on the reactions of their participants, noting, in particular, which parts of the training draw the most resistance or generate the most confusion. They then refine the materials accordingly. For example, the team hear regularly from law enforcement personnel that they “keep being called to revive the same people again and again.” “There was real resistance to rewarding risky behavior—which isn’t surprising, ”says Winograd. To see if it was possible to reduce this resistance, the team added a question to the training’s pre- and post-test evaluation (“Should there be a limit on how many times a person can be revived using naloxone?”). They also modified the training to directly address the officers’ resistance to “rewarding” repeat drug users with naloxone. Post-test responses reveal that these changes are having an effect. “After every training, we see the needle moving in the right direction. More officers are responding “no” to the question about limits, indicating growing receptivity to the idea of using naloxone repeatedly.”