NEXT Distro: Naloxone Affiliate Mailing Guide: August 2021

NEXT DISTRO

NALOXONE AFFILIATE POLICIES AND PROCEDURES www. n e x t d i s t r o . o r g / n a l o x o n e

IN THIS GUIDE History, Mission, and Vision- 2 Directing Supplies to Those Most At Risk- 3 Supply Basics- 4 Personal Connection- 5 Addressing & Packaging- 6 Using PirateShip- 7 Receiving & Tracking- 10 Sheet Notifications- 11 Aggregate Data- 12 Co-branding- 13 Troubleshooting- 14 Agreements- 15

THANK YOU FOR BEING OUR PARTNER Jamie Favaro jamie@nextdistro.org 917-828-0293

Thank you for choosing to join NEXT Distro's team and expand naloxone through mail-based distribution in your state via nextdistro.org/naloxone First and foremost, our site is your site. NEXT is committed to reducing opioid overdose mortality through expanding online and mail-based harm reduction nationally. We need your help to ensure nextdistro.org works for people who cannot access

Dan Coello dan@nextdistro.org 646-389-0752

naloxone any other way.

We have big dreams to support a groundswell of power among people who use drugs. Shifting lifesaving resources into the hands of impacted communities is the first step. We are grateful for your partnership and collaboration, and look forward to building NEXT Distro together.

Version: Nat072521

History, mission, and vision NEXT Harm Reduction "NEXT Distro" or "NEXT" is an online and mail-based harm reduction program founded in 2017. NEXT's mission is provide online and mail-based harm reduction supplies and support to people who use drugs that cannot access in-person syringe service programs.

After receiving so many requests for naloxone from friends and family of people who use drugs, NEXT launched a naloxone-specific website www.naloxoneforall.org in 2018. This site included a brief video training, quiz, and enrollment to have naloxone mailed to households at no cost.

Although this sister site was originally developed as a New York State-specific Opioid Overdose Prevention Program, needy requests for free naloxone streamed in from across the United States soon after the site went live.

To support the requests that NEXT was receiving nationally, an affiliate 'hub and spoke' model was was created. Because naloxone laws are state by state, NEXT partners with in-state harm reduction organizations to distribute naloxone to requestors in their state. This means that affiliate programs mail their own naloxone, using their own staff and resources, to residents in their own state.

In October 2020, NEXT folded functionality from naloxoneforall.org into nextdistro.org/naloxone. The purpose of this merger was to consolidate resources and avoid public, participant, and stakeholder confusion about why there were two NEXT sites.

Since launching, NEXT and affiliate partners have provided free online opioid overdose responder trainings and no-cost naloxone to over 26,000 households across 50 states and Puerto Rico. This broad geographic distribution is thanks to state affiliate programs.

NEXT's vision is to create a national resource for mail-based harm reduction services using a hub and spoke model. We believe there is power in partnership. NEXT also anticipates that information we learn about why individuals cannot access naloxone in-person has the potential to change restrictive policies.

More information can be found on nextdistro.org/history

Directing supplies to those most at risk Preventing opioid overdose death means getting naloxone to those most at risk of witnessing an overdose We know that putting naloxone into the hands of people who use drugs and their networks/ communities is the best strategy to reduce opioid overdose fatality. It is for this reason that we support our affiliate partners in taking liberties with the amount of supplies provided- specifically to people who have filled out the overdose incident form, witnessed an overdose in the past year, or who they themselves have overdosed in the past year. Indications provided by each individual during their enrollment provide a window into the amount of supplies that should be sent.

Additionally, NEXT works to resources individuals that have been traditionally shut out of health and social service systems or who may have difficulty or anxiety around in-person resource access.

We provide some guidance and thoughts below.

NEXT Distribution Priorities Supply naloxone to people who use drugs.

Supply naloxone to people who are closely connected to people and communities of people who use drugs.

Supply naloxone to people who have recently been released from jail or prison, and their friends/family.

Supply naloxone to people and communities that have been devastated by by structural violence and the war on drugs. This includes BIPOC (Black, Indigenous, People of Color), gender nonconforming individuals, PWUD, people who speak languages other than english, and those with no health insurance.

Supply naloxone to people in rurally isolated parts of the state where naloxone access options are limited.

Getting Naloxone to People Who Use Drugs Our goal is to get as much naloxone to communities of people who are most likely to be the first responder to an opioid overdose emergency. This generally means distributing naloxone to people who use drugs and their roommates, friends, family, and other loved ones.

Whenever there is an opportunity to provide an enrollee more than one kit, we encourage affiliates to do so. There are many situations in which NEXT strongly urges partners to provide more than one kit: During the refill process after an opioid overdose incident has been reported.

If the enrollee identifies that they themselves have overdosed in the past year.

If the enrollee identifies that they have witnessed an overdose in the past year.

If the enrollee makes any type of request in their enrollment for more than one kit or indicates that they are connected to people who use drugs or if they themselves use drugs.

A note about emphasizing the term "people who use drugs" rather than people who inject drugs or people who use opioids: NEXT intentionally uses the term "people who use drugs" to include all individuals who put illicit and unregulated substances into their body. Because people who use drugs can not be sure what they are putting into their bodies (without extremely expensive equipment such as a spectrometer) and because broad evidence of fentanyl cross-contamination exists across substance types, we err on the side of caution and assume that any untested drug poses some potential risk for opioid overdose.

Supply basics: Everything you need 1. Plain bubble mailer

.

Bubble mailers are a cost-effective alternative to boxes. We prefer 6 x 9 inch or 8.5 x 12 inch selfadhesive bubble mailers for shipping 1 -3 naloxone kits, CD/DVD bubble mailers (7 x 7 inch) will also work for Narcan but not intramuscular naloxone. If you are shipping larger amounts of naloxone you will need a larger bubble mailer or plain box.

2. Pen Use a pen or pencil to write a personalized note on the pamphlet.

3. Pamphlet NEXT will work with you to customize and co-brand a pamphlet template, one area of the pamphlet is always left blank for a personalized message from the sender.

5. NEXT promotional postcard If requested by the affiliate and financially viable, NEXT will provide co-branded promotional postcards to include with mailings. We usually include several for folks that have experienced or witness an overdose, and ask them to give to others they know who need naloxone but can't access it.

6. Narcan Nasal Spray or Intramuscular Naloxone Kit We cut Narcan boxes to ensure easy packing, see page 3.

7. Overdose Incident Report Sticker The overdose incident report url should be somewhere on the Narcan or naloxone package. The sticker will remind an individual responding to an overdose that there is an online report form.

8. Scissors 9. Tape 10. $4.00 USPS stamp or Thermal Printer NEXT always uses United States Postal Service for shipping, their service is quick and inexpensive. If volume is significant and/or cost is an issue, we suggest using online postage service like PirateShip.com which provides significantly discounted postage. PLEASE NOTE: Postage costs are likely to increase over time.

11. Scale We use a small kitchen scale to weigh packages that may be over 4 ounces- as can be the case if mailing multiple naloxone kits in one package.

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Achieving a manageable package size If you' re mailing Narcan nasal spray, break down the box to achieve a flat package.

1. Open the Narcan box and take out the two Narcan devices, set aside.

2. Cut the front instruction panel off the Narcan box. Be sure to cut around the instructions so that the twopage manual remains intact. This is the part of the package to be included with the shipment.

3. Discard the remainder of the box.

Overdose incident report url stickers We use stickers to remind overdose responders to fill out our online reversal form. We've found that stickers affix best to the paper backing of the Narcan dose.

When someone fills out this form, we will add the report to our shared spreadsheet, as well as add a request for you to send replacement kits.

Contact us if you need more pre-printed stickers!

NEXT recommends mailing out at least three replacement kits if possible.

If you mail intramuscular naloxone, NEXT has IM-specific stickers, or you can affice the general reversal sticker to the IM naloxone package.

ensuring a personal connection Make sure folks receiving supplies have pertinent information and feel comfortable reaching out.

A hand-written note is an important part of creating a connection with the individual receiving supplies.

Your note can simply invite them to reach out if they have questions or concerns. You can also respond to a question on their enrollment or comment on something they reported and/or offer to connect them to inperson support, provide other location-specific information, or any other personal touch that underscores your interest in supporting them.

Essential tips for the personalized note Do not address your note to a specific person or include their name in your correspondence. For example, use "Hey there" instead of "Hey Jamie." This will help ensure that a found pamphlet does not identify its recipient.

Read the enrollment information before writing a note.

Many enrollees ask questions or provide information about help they are interested in. You can use their comments as a jumping off point for your personal note.

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addressing and packing shipments Choosing a return address In our experience, about one out of every 50 packages is returned. The reasons for this include an error in the enrollment or in the address transcription. In many cases, an apartment or lot number is left off the shipping address. For this reason, it is important to include a legible return address on each package. NEXT strongly requests using an acronym if the return address is an organization. You can also use the name of the individual shipping/ most appropriate to receive and manage returned items. The return address needs to provide a measure of confidentiality about where the package is coming from. I.e., It's important to write HHRC instead of Hometown Harm Reduction Center. Whenever possible, use a PO Box or return address that is disconnected from the organization.

Addressing shipments Utilize data from the affiliate Google Spreadsheet to populate the TO: addressee information. Write legibly and ensure the address is correct. Alternately, you can use Pirateship.com and a thermal printer to print postage stickers.

Package security and USPS Flags USPS may 'flag' a shipment for security screening for various reasons. In these cases, packages will pass through tests to ensure they have not come into contact with explosive material, or are carrying illicit substances. Generally, packages should pass through security unopened but there may be a shipping delay.

Some reasons why USPS may flag a package: No return address

For Problematic Addresses

Return address is incomplete, i.e., address but no

Email the individual using the contact

name

information they provide. Explain why the

No name or an incomplete name, i.e., "John"

provided name or address is problematic and

The addressee is a pseudonym or "John/Jane Doe"

request proper information.

If the individual is high-risk, wait 24 hours to hear back before mailing the package to originally provided name/address. If the person is not high-risk, wait 36-48 hours. It is permissible to email more than once.

Packing Tips Address the package or affix postage sticker before the packing process.

Put flat materials into the package before loading bulky items.

If the closure seems unsecured or precarious, tape it shut with packing tape.

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Using pirateship to purchase POSTAGE One postage purchasing option NEXT prefers is PirateShip.com PirateShip/pirateship.com is a free online USPS-approved shipping software.

Single Package

NEXT began using PirateShip

Several Packages of the same size and weight

(and a Rollo thermal printer) after learning about the time-saving ease of use and deep discount.

Depending on the number of packages you have, you can create one mailing label at a time or several. If the packages are the same size and weight, PirateShip provides a bulk upload function.

Single Package Process To mail a single package using PirateShip you'll need the mailing name and address, diameters of the package, and weight. Most naloxone packages are under 4 ounces. Because 4 ounces (or anything under) will always be the same price, it's fine to mark basic 1 or 2 kit packages as 4 ounces. If you are mailing 3 or more naloxone kits, you should weigh the package.

After typing in the recipient's name, mailing information, and details of the package, you can press the green GET RATES button.

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The next page will confirm the recipient's address, return address, and other details. Press the green BUY LABEL button. If anything is incorrect you can simply press your browser's back button or use PirateShip's Previous Step option. At this stage if you've noticed there is something terminal about the label, press Cancel & Delete Label.

After you have purchased the stamp the next window will show information related to the postage and package shipment. Use the PRINT LABEL button to print the postage label.

When printing, you can print using your regular printer and affixing the postage to the package with tape. Another option is using a thermal printer. We prefer Rollo. If using a thermal printer, make sure the paper size is set to 4.00 x 6.00.

Bulk Package Process If you have several package that are the same size and weight, using a bulk upload option is an excellent time saver. We recommend uploading names and mailing information using an .xls spreadsheet. The bulk upload option allows you to purchase multiple postage stamps at the same time without having to enter each address individually into PirateShip.

When you are creating the bulk upload .xls include columns for a) name, b) address, c) city/town, d) state, e) zip.

The first row of your spreadsheet will be used to align columns with the PirateShip uploader, be sure that a dummy/example name and address is on first row of your bulk upload. The first row is not charged for or printed

by Pirateship.

See example highlighted in yellow.

Once you have uploaded bulk addresses via .xls you will be prompted to purchase the postage in a bulk rate and the print option will include the postage stickers for the full list of addresses you have uploaded. Using this option you can print dozens of mailing labels in just a few seconds.

Problem Solving Thermal Printing/ PirateShip Most troubleshooting involving the Rollo thermal printer can be found on http://support.rolloprinter.com/support/home. NEXT choose the Rollo brand because of its ease to set-up and troubleshoot. Contact us if there are issues that are not resolved through restarting the machine or using the Support website.

If you realize you've made an error on the address after purchasing postage, you can use the Refund Label button on the bottom right hand corner of that label's info page. Asking for a label to be refunded will trigger a 2-3 week process with USPS to ensure the label was never used.

Simply request a refund and begin the process over again using correct information.

If your organization uses a NEXT credit card to pay for postage and wants to use the thermal printer and PirateShip to mail other organizational packages not having to do with NEXT, simply add a payment method using Settings and choose that payment method for the specific shipment. Make sure the NEXT credit card is marked as the default payment option. Contact NEXT if your organization accidentally mails organizational mail using the NEXT credit card payment method.

Receiving and tracking requests NEXT currently uses Google Drive to communicate and track requests When NEXT receives an enrollment, it's captured in a master spreadsheet. We'll then populate our shared spreadsheet with enrollment/naloxone requests.

The spreadsheet will include data points such as demographics, if the enrollee has ever received an overdose responder training before, if they themselves have overdosed in the past year, or if they've witnessed an overdose in the past year. You are welcome to utilize aggregate data from the spreadsheet for your own reporting and advocacy purposes. Names and addresses are treated confidentially.

Each time a request comes through, NEXT will update your spreadsheet with a new row (see Fig. 1). After you have filled the request, use the checkmark function to indicate the request has been filled, enter the order-fill date, and the number of doses distributed in column A-C (see Fig. 2).

Please note that column F indicates the name to be written on the shipment and overrides column E if it is populated.

Fig. 1

Fig. 2

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setting up spreadsheet notifications Ensure you know when new requests come in When NEXT staff adds a new request to your affiliate spreadsheet, it's important to fulfill the request in a timely manner. Setting up spreadsheet notifications will alert you via email when the spreadsheet has been updated. You may choose notifications on an 'as edited' or daily basis.

To set up spreadsheet notifications, go into the affiliate spreadsheet, choose Notification Rules... from the Tools dropdown menu (see Fig 1). From the "Set notification rules" box, choose to notify you when any changes are made. You can choose whether the system notify you in a daily digest, or right away (see Fig 2).

Fig. 1

Fig. 2

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Aggregate data Get a quick snapshot of who is making requests in your state On your affiliate spreadsheet, we include a tab called "Reporting". This conditionally formatted spreadsheet pulls in data from order requests to provide you a snapshot of who is making requests in your state. It can provide valuable insight into who the project is-and isn't-reaching.

Promotion nextdistro.org/yourstate is yours to share The extent to which you promote your state's nextdistro.org site within your state is up to you. Some affiliates choose to send the site to individuals who call requesting naloxone but are too far to receive it in-person. Other affiliates choose to promote the site more proactively in their networks. Mailing supplies takes time and money, some affiliates are able to expand more than others based on these factors.

Below are some thoughts we have about successful promotion:

Word of mouth promotion among people who use drugs is the most impactful way to get people who are most likely to respond to an opioid overdose emergency naloxone through nextdistro.org/naloxone. We suggest including extra promotional postcards in the packages of enrollees who have overdosed in the past year or witnessed an overdose. Extra postcards should also be included in counties and within demographic groups that are at higher overdose risk. Your organization can appeal to enrollees to share these postcards within their network and to others who can not access naloxone in-person.

When social media blasts occur over Facebook, the site gets a rush of supply requests but usually from individuals who have not personally experienced or witnessed an overdose in the past year and want it "Just in case I see someone who overdoses". When promoting via Facebook it is essential to do so mindfully and with a focus on impacted communities.

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co-branding on printed information We love co-branding with our affiliates and partners Affiliates send a co-branded pamphlet with each shipment. The sections are: How to Respond to an Opioid Overdose, What do I do if I used my naloxone?, and Why is rescue breathing important?. You are able to co-brand, edit, and add to this pamphlet template, we welcome it. You are also invited to send out your own organizational materials and any supplemental information or education.

At minimum, 1/6 of the pamphlet is left blank for affiliate use (program information, contact, website, etc).

Pamphlets are created in a shared Google Doc and can be edited by affiliates and NEXT. NEXT requests that affiliates not edit template text without notification.

Budgeting and support We recognize that getting naloxone to people through the mail costs time and money. Below are some of the expenses to think about as you design your naloxone mailing program: Postage- each package will cost about $4

Advertising palmcards or other materials

Mailing supplies such as bubble mailers

Advertising on social media or google if you

Staff/volunteer time to pack naloxone, address

choose to do so

envelopes and write hand-written notes

Additional program supplies as needed

Time and transportation needed to bring packages to the post office If your organization has naloxone and the staff/volunteers to support mail-based fulfillment but the postage and bubble mailers are cost-prohibitive, please let NEXT know. Although NEXT does not have an excess of funding to support state expansion, we may be able to have a fundraiser or redirect donations to raise money for this purpose.

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Troubleshooting: issues, errors, and expectations When things don' t go as planned.

Like any other organization, issues and errors are bound to arise. Below we've outlined some challenges and suggestions. It is important to communicate immediately if any significant incidents arise that put individual safety or program operations in jeopardy.

An enrollee reports that their package arrived ripped open, or the supplies inside were broken Although NEXT and affiliate partners have mailed over 26,000 packages, we have only once received a report of intramuscular naloxone vials breaking in the process of being mailed.

NEXT has received reports of packages coming ripped (3), or inspected by USPS security (1). The ripped packages were all reported around times of heavy volume for the USPS. We anticipate the rippage was caused by USPS scanning/sorting machinery. One enrollee accused a neighbor of tampering with their mail. While it is difficult to pinpoint the origin of the damage, our priority is to get a replacement package to the individual as soon as possible.

The one incident NEXT experienced with a naloxone package being opened and inspected by USPS security was in a metropolitan city after the program affiliate used a mailbox to mail the package. It is important to bring packages directly to the post office due to heightened concerns about mail security.

If an enrollee reports that their mail was open or damaged: Gather as much information as possible about the incident from the enrollee and report it directly to Jamie Favaro via email. Be sure to ask the enrollee if they have ever experienced issues with their mail before and also request a photo of the package.

Send a replacement package as soon as possible.

An enrollee reports that their package did not come NEXT estimates that about 1 in 50 packages does not get delivered properly. This may be due to an error in the enrollment address or some omission on the address (usually apartment or lot number).

NEXT attempts to mitigate these errors by sending an automatic email to each enrolled confirming their name and address.

If an enrollee reports that they have not received their package: If using PirateShip you can view the status of a package using the USPS tracking number Confirm the enrollees mailing information is correct on the shared spreadsheet and PirateShip Send a replacement package as soon as possible.

If a second package does not arrive, request an alternative address from the individual.

If the enrollee suspects that their package is being stolen, you may request signature confirmation on the package. On PirateShip signature confirmation is an option on the 'Create Label' page.

Your agency shipper will be out of town and no one is available to mail packages If there is any instance where staff/volunteers responsible for mailing supplies will be away for more than 3 business days, please notify NEXT as soon as possible. NEXT will make accommodations to mail supplies from the New York office during that time.

I'm having difficulty accessing our spreadsheet/ the spreadsheet looks like something is wrong If at any time you identify an abnormality in the shared spreadsheet between NEXT and your agency, report it to NEXT immediately. Email dan@nextdistro.org and cc: naloxone@nextdistro.org Someone told me it's illegal to put naloxone in the mail NEXT affiliates do not mail anything that is hazardous or against USPS regulation. Furthermore naloxone is not a controlled substance.

a few important notes Fulfillment Turnaround Time Organizational partners strive to send requested supplies next day or within 48 business hours. To meet this goal it is important to: Ensure supplies such as naloxone and bubble mailers are in-stock, order replacements in advance.

Locate supplies together to make packing and mailing easier.

Ensure there are enough copies of kit inserts on-hand, make extra copies on down time.

If staff are having a challenge mailing supplies promptly, attempt to tier mailings by order of importance. For example: Opioid overdose incident refills should always go out same or next day.

Requests from people who have they themselves overdosed in the past year or who have signaled on their enrollment that they need naloxone as soon as possible should also be given top priority.

If it is necessary, your agency can move back low-risk individuals on the queue to ensure those most likely to respond to an opioid overdose are prioritized.

Spanish Language Resources NEXT's training platform has a Spanish-language widget which enables a quick Spanish translated version. We also have a Spanish-language training, quiz, and enrollment. If you have concerns about receiving enrollments from Spanish-speaking individuals, please reach out to us for assistance.

Overdose Incident Reports A reversal report is listed at www.nextdistro.org/reverse. The NEXT pamphlet emphasizes the importance of filing out the reversal form. All reversals within an affiliate state will be reported to affiliates within 48 hours.

Agreements Privacy and Security of Enrollees Under no circumstance may enrollee names, addresses, or other identifying information be shared beyond the immediate individuals working to fulfill shipments. Affiliates will work to ensure no enrollee information is put at risk of being shared, this means attention to technological security (having 2-step Google authentications, signing out of Google Drive when not in use, passwordlocked computer and phone) and leaving packages face down when in the presence of non-affiliate folks.

Absolutely No Pay-per Services Naloxone received via nextdistro.org is free to all enrollees. Affiliates will not request or expect to be compensated by enrollees for supplies mailed to them.

Bidirectional Communication is Essential When we say affiliate we mean partner. We need your partnership to make this project work. What that means for us is to tell us if something isn't working, if something could be running better, managed better, more, less, bigger, smaller, quieter, louder, all the things. We want you to feel ownership over this project and process. Let's talk.

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