View from the Field: Findings of the Boston Overdose

Linkage to Treatment Study (BOLTS)


By Ranjani Paradise, PhD, with contributions from Dan Dooley

Ranjani Paradise, PhD

Director of Evaluation

Institute for Community Health

With funding from RIZE Massachusetts, the Institute for Community Health (ICH) and collaborators from the Boston Public Health Commission (BPHC), Boston Medical Center (BMC), and BU School of Public Health (BUSPH) conducted a qualitative research study called the Boston Overdose Linkage to Treatment Study (BOLTS). The study examined access to treatment for people who recently experienced an opioid overdose in Boston, with particular focus on racial/ethnic equity. The study design and data collection were guided by input from a wide range of stakeholders, including front line service providers and people who have lived experience with addiction from the Black and Latinx communities. BOLTS included interviews with 59 overdose survivors in Boston as well as 28 key informants including policymakers, healthcare providers, harm reductionists, first responders, and community leaders. 

RIZE reached out to two leaders of this research, Ranjani Paradise, Director of Evaluation at ICH, and Dan Dooley, Director, Research and Evaluation Office at BPHC to discuss the findings.

1. Can you tell us more about the impetus behind this study? What motivated you and your colleagues to conduct it? What was the timeline and scale? What pre-existing data did you use to inform your approach? 


BOLTS was motivated by a quantitative data analysis led by BPHC in 2018-2019 using the MA Department of Public Health Data Warehouse (Dooley et al., Boston Public Health Commission, 2019). This analysis found that after adjusting for important risk factors, Black and Hispanic/Latinx Boston residents were significantly less likely than their white counterparts to access substance use disorder treatment within 30 days of an opioid overdose. 


We designed BOLTS as a qualitative study to explore the “why” behind this disparity and identify opportunities for programmatic and systems change to improve equity in access to post-overdose treatment. To develop solutions that meet community needs, we felt that it was critical to hear directly from people of color who have experienced an overdose and learn from their experiences and perspectives. We also wanted to hear from people who work with overdose survivors, and learn from their deep knowledge of the local treatment and harm reduction systems. 


BOLTS kicked off in November 2019. We developed a Research Steering Committee of local policymakers, healthcare providers, researchers, and service providers, including people who had lived experience with addiction. By February 2020, we had designed a recruitment plan and data collection tools with the Steering Committee’s input. And then the COVID-19 pandemic hit. Our partners had to immediately turn to pandemic response, and we had to redesign the study to include remote data collection procedures as well as new areas of inquiry related to the pandemic - as we all know, COVID-19 dramatically altered access to treatment and services, and BOLTS needed to be responsive to that context.  


We ended up starting our key informant interviews in September 2020, and started the overdose survivor interviews in January 2021. We wrapped up data collection in September 2021, and have been engaged in analysis, reporting, and presentations of findings since then. With 59 overdose survivor participants and 28 key informants, we had thousands of pages of transcripts to analyze, and we are taking care to honor everything participants told us and make sure we are not overlooking any of their experiences and stories as we summarize findings. We are so excited to be at the point where we can share findings and elevate the voices of diverse overdose survivors in the ongoing discussions about reforming the behavioral health care system in Massachusetts. You can find some presentations here, and stay tuned for additional publications forthcoming! 

2. What was the nature of the interviews, and how did you incorporate data analysis into them? What sort of information did you seek to discover from the participants? How were they recruited?  


We had two different participant groups. First was the overdose survivors. We recruited participants who had experienced an overdose in the past three months and were living in the Boston, and we did purposive sampling to ensure racial/ethnic diversity. Of the 59 survivors we interviewed, 23 identified as Latinx, 18 as Black, and 18 as white. To recruit participants, we worked primarily with two partner programs – BPHC's Engagement Center (EC) and BMC’s Project TRUST. I want to give a huge shoutout to these partners because BOLTS never would have happened without them. Staff at the EC and Project TRUST identified clients who met our inclusion criteria and provided a warm handoff to study staff.  


After screening and consent, we did a demographic and drug use history survey with participants, followed by a qualitative interview about drug use history, experience with their most recent overdose, experiences with and perspectives on treatment and services, impact of COVID-19, and recommendations to improve access and equity. We ended up doing most of the interviews in person at the EC, and because of the nature of the recruitment, most study participants were living or spending time in the Mass. and Cass area of Boston when we spoke with them. This makes their insights and perspectives especially timely and relevant, with so much media and policymaker attention on the situation in this area.  


With our analysis of the overdose survivor interviews, we looked for themes across the participant group as a whole, and also examined themes for Black, Latinx, and white survivors separately to see if there were differences. In addition, we did a targeted sub-analysis for participants who were living on the street in the Mass. and Cass area at the time of the interview, to understand and elevate the unique needs and perspectives of people experiencing unsheltered homelessness. 


The second participant group was key informants who work with overdose survivors in a range of professional or community roles, including policymakers, first responders, healthcare providers, harm reductionists, and community leaders. For key informants, we did a qualitative interview by Zoom or phone and asked about their perspectives on treatment and services, decision-making about treatment, barriers/facilitators to access particularly for Black and Latinx people, impact of COVID-19, and recommendations to improve access to and equity in treatment and services. 

3. How did the research team ensure collaboration across such a wide range of stakeholders?  


Our study team includes co-investigators from four institutions (ICH, BPHC, BMC, and BUSPH) as well as research staff from ICH, BPHC, and BMC. We have an incredible team with research, public health, health equity, and medical expertise, and this has been a huge asset for the study. Most of us had not worked together before BOLTS, so we made sure to talk about roles early and often and to have regular meetings. This helped us make sure the whole team could provide input at key points and that we could adjust roles based on capacity and interests.

 

We also provided opportunities for the Research Steering Committee to review and give feedback on tools and recruitment plans, and gathered additional input from BPHC’s Recovery Services staff and Project TRUST. All of these stakeholders are deeply invested in improving access to services and addressing inequities, and their perspectives strengthened our work. 

4. What were some of the key findings of the study? Were any of the results unexpected? What were the main takeaways of the study we can apply to better tackle racial/ethnic inequities in treatment and our fight to end the overdose crisis? 


First, it is important to understand the characteristics of the overdose survivors we interviewed. To highlight just a few things, about half (49%) were living on the street, a quarter (25%) were staying in a shelter, most (85%) had been incarcerated in the past, most (83%) reported using stimulants in addition to opioids, and most (85%) had experienced multiple overdoses in the past year. Overall, the people we interviewed had multiple characteristics that contribute to marginalization as well as risk of future overdose.  


Participants shared so much rich and powerful information with us, and there's no way to cover everything in a brief summary, so I’ll just share some highlights here in a few categories. This is focusing on findings from the overdose survivor interviews, but these themes were also supported by key informant data: 


Past experience with treatment and recovery: One thing that was surprising for us is that almost all (97%) of the people we interviewed had engaged in some kind of substance use treatment program in the past, and many of them had had periods of recovery in their lives. However, for many complex and nuanced reasons, the participants returned to drug use, and the majority (58%) had not accessed any kind of treatment in the time between their most recent overdose and the BOLTS interview.  



Key takeaway: The survivors we interviewed were very knowledgeable about treatment options and were quite experienced with treatment. Hearing their stories highlighted that we cannot think of treatment as a “one and done” situation. Recovery can be a lifelong journey, and return to use is often part of that journey – we need systems that offer long-term support and help facilitate easy re-entry into treatment when someone seeks it.  


Interpersonal interactions with staff: The interactions that overdose survivors had with staff at various programs made a big impact on how they felt about services and what they decided to engage in. Unfortunately, but unsurprisingly, many survivors talked about feeling stigmatized and being treated with disrespect in their interactions with staff at substance use disorder treatment programs and hospitals, and feeling dehumanized was a common experience. In addition, some Black and Latinx participants shared experiences of interpersonal racism. While these negative experiences were common, there were some places where survivors felt especially cared for and respected by staff, most notably the BPHC EC. We learned that many survivors prefer to work with staff who have similar identities and/or experiences to their own. This helped them feel understood, and built trust and engagement. Many people we interviewed emphasized that they want to work with staff who have lived experience with addiction, and some talked about other aspects of shared identity or experience, including racial/ethnic identity and knowing what it’s like to be homeless. As one overdose survivor said,


“[Programs should hire] people that are recovering, yeah, because like you can read a book on it all you want, but you still never walked in those shoes.”  


Key takeaway: Stigma and racism are present in many healthcare and substance use disorder treatment programs, and we need to continue to focus on addressing this in order to engage and retain people in services. In addition, we need to ensure that the staff providing care bring empathy and compassion to their roles and can build trust and connection with clients. This is facilitated by having staff with strong interpersonal skills who reflect the communities being served (across multiple aspects of identity and experience), and this should be a key priority for programs. And last but not least, we must address trauma and burnout among frontline staff if we want to have an effective and sustainable workforce.   


Social determinants of health (SDOH): One point that is absolutely critical is that quality-of-life is not just about whether or not a person is using drugs. Many of the survivors we interviewed were living without housing, employment, or the most basic of amenities. The SDOH and having a sense of safety and security were absolutely paramount when people reflected on what they needed and wanted for their lives in general and to move towards recovery – as one person said,


“I think the most important thing to recovery is knowing you have a safe place to go every night.”


Key takeaway: We can’t try to address a person’s substance use disorder in isolation from their life circumstances, especially for people who are living in unstable and traumatic conditions. Treatment and recovery support services need to take a whole-health approach that includes addressing SDOH needs. This is also critical for race equity, as we know that structural racism has led to people of color having a disproportionate burden when it comes to SDOH. 


Trauma and mental health: Many of the survivors we interviewed spoke about past or current experiences of trauma (in addition to the trauma of overdose itself). Some also talked about having mental health conditions such as depression or anxiety, and a few had serious mental illnesses. This was related to SDOH for some people, for whom homelessness and other social needs led to mental/emotional distress. Several participants described using drugs to cope with their untreated or unmanaged mental health conditions, and participants also described experiences in which having a co-occurring mental health condition and an active substance use disorder presented barriers to treatment. For example, one participant described having anxiety and panic disorders, and said that his provider stopped his anxiety medication prescription because he was using opioids. This participant felt that he could not successfully complete a substance use treatment program without having his mental health medication, saying:


"If I could get my medication [...] I'll be in the program so fast. In a sober house and working. I know I can't do [a program without medication] and I don't want to burn the bridge until, because I have such bad anxiety and panic attacks and all that I know I won't stay."  


Key takeaway: The stories we heard from overdose survivors underscore the ways in which mental health, substance use, and SDOH (particularly housing insecurity) are deeply intertwined, can compound one another, and can create barriers to care that make it even harder to recover. We need treatment systems that better integrate mental health care and substance use treatment, in addition to addressing SDOH. 

5. How can this study and others inform our practices and policies to address needs identified in the findings? What future research in this area is needed? 


One key meta-finding from BOLTS is that overdose survivors have a wide range of experiences and individual needs and priorities – studies like this help us understand the commonalities as well as the unique perspectives that can help us create a system that is accessible, welcoming, and effective for people with many different life stories. To distill it down to the core, the BOLTS findings call for person-centered, individualized care that can be tailored to each person’s circumstances and goals. No community or population is a monolith, and there is no one-size-fits-all change to the treatment system that will address all of the complex and overlapping challenges BOLTS participants face daily. Long-term sustainable solutions will require different sectors – including medical, behavioral health, and social services -  to work together to implement changes and create multiple accessible pathways to recovery to accommodate various preferences. However, more localized improvements, including bringing in more staff with lived experience and diverse identities, will make a difference that could be life-saving for some people. Finally, in addition to substance misuse, BOLTS participants’ lives often included trauma related to homelessness, incarceration, and racism. This points to a strong need for more pervasive trauma-informed care that acknowledges the complexities of these different experiences. 


There are so many possibilities for future research! First, there were some limitations with our study sample – for example, most of the people we talked to were living in the Mass. and Cass area, and about 70% identified as cisgender male. Future research should seek to learn about the experiences and perspectives of people living in other parts of the city, females, and transgender people, to understand their unique priorities and needs when it comes to treatment and supports. Furthermore, BOLTS examined the experiences of Black and Latinx people broadly, and future research could focus on more specific ethnicities or cultural communities within those categories, as well as other racial groups. In addition, more research is needed on polysubstance use to understand the reasons people use multiple substances and the kinds of treatment approaches that work best for this. Finally, as our systems of care evolve, we need studies that help us understand what works well, for whom, and in what contexts.  

6. Why is it important for organizations like RIZE to continue funding these types of studies? 

  

If we want to develop program and policy solutions that address the opioid epidemic and improve the health and wellbeing of marginalized communities, it is essential that we involve the people who are directly affected by the issues at hand. Qualitative, equity-focused research like BOLTS gives us a way to elevate the voices of people with lived experience using systematic and rigorous methods. This kind of research can also help humanize issues and push back against stigma and harmful narratives about people who use drugs. We are so appreciative of the funding that RIZE provided for BOLTS and RIZE’s ongoing commitment to involving people with lived experience in their work!  

Acknowledgements:

I want to acknowledge all the study team members who participated in the development, data collection, and/or analysis for BOLTS: Angela Bazzi, Jaylen Clarke, Jeff Desmarais, Dan Dooley, Andres Hoyos-Cespedes, Mark Kennedy, Sim Kimmel, Al Nurani, Shannon O’Malley, and Sunday Taylor.


On behalf of the team, thank you to all of the study participants who contributed their time and expertise to this work.

About RIZE Massachusetts

RIZE Massachusetts Foundation is solely dedicated to funding and creating solutions to end the overdose crisis. Guided by those with lived experience and unafraid of new ideas, RIZE is building networks, designing programming, and supporting community partners who are using novel approaches to preventing overdose and increasing access to treatment.


For more information visit www.rizema.org

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