Tulsa is poised to be nation's first 'Zero Overdose' community

August 30, 2023

As Tulsa’s first responders were called to more and more overdoses in recent years, Captain Justin Lemery knew the city’s Fire Department needed to act — to do something that could stem these crises before they happen. 

Oklahoma is in the thick of what experts have called the fourth wave of the opioid epidemic, driven by a rise in opioids and psychostimulants like methamphetamine being used together. In Tulsa, the Fire Department responds to about eight overdoses a day, said Lemery, the department’s director of emergency medical services. 

“We couldn’t continue to just stand by and not try to do something more than just respond,” Lemery said. 

Spurred by a concerning rise in methamphetamine-related overdose deaths in Tulsa County, Lemery and other community leaders convened this spring to share knowledge and strategize around their role in preventing overdoses as part of the first cohort of Tulsa’s Zero Overdose learning community. 

A rise in co-use of opioids and psychostimulants like methamphetamine is driving the fourth wave of the opioid epidemic in Oklahoma.

Launched by Healthy Minds in March 2023, the Zero Overdose learning community is a collaborative of citywide partners dedicated to eliminating overdose deaths in Tulsa. It’s modeled after the national Zero Suicide initiative, a well-known suicide prevention framework implemented in behavioral health systems. 

Over two months, 17 people from six organizations — including behavioral health providers and first responders — met to learn about overdose trends, harm reduction, risk screening and safety planning, and data collection and evaluation. Now, those organizations are taking what they learned and putting it into practice across Tulsa.

With plans for future cohorts in the works, Tulsa is pioneering the concept of a “zero overdose community” and is poised to become a national leader in addressing overdose deaths. 

The Zero Overdose vision

Zero Overdose aims to eliminate overdose deaths through a seven-element framework. Groups that commit to becoming Zero Overdose organizations work to:

  • lead a culture change within their organization
  • train staff to compassionately work with people who use drugs
  • screen for overdose risk
  • create a safety plan for those at risk
  • treat individuals at risk
  • transition individuals throughout the continuum of care with warm handoffs
  • collect and track data regarding their overdose prevention practices
A graphic shows the seven elements of the Zero Overdose framework: LEAD a culture change committed to reducing overdoses; TRAIN a competent, confident, and caring workforce; IDENTIFY individuals with overdose risk; ENGAGE individuals in an overdose safety plan; TREAT individuals at risk of overdose; TRANSITION individuals through care; IMPROVE policies and procedures through data collection and evaluation.
Groups that commit to becoming Zero Overdose organizations follow a seven-element framework designed to eliminate overdose deaths.

Because Zero Overdose is based on the nationally recognized Zero Suicide initiative, the framework was familiar for many organizations participating in the learning community. The foundational belief of Zero Suicide is that every suicide death is preventable, and the initiative gives systems the framework to implement that prevention work. Similarly, Zero Overdose operates on the belief that overdoses are preventable, and Tulsa can work toward a future where the community has zero overdose deaths.

“Our agency is huge in Zero Suicide, so [Zero Overdose] was that same kind of mindset,” said Kimberly Hill-Crowell, the chief clinical officer of GRAND Mental Health in Tulsa. “We need to approach it in that same way. We need to say, ‘This is preventable for everyone.’” 

The Zero Overdose learning community was an opportunity for Tulsa organizations and agencies that may not typically collaborate to connect and share knowledge. GRAND, the Tulsa Fire Department, the Tulsa Police Department, Family & Children’s Services, Tulsa Center for Behavioral Health, and Housing Solutions each participated in the first cohort, facilitated by Healthy Minds.

“[Healthy Minds] did a great job of bringing great people together, which I think is important because we know, as the Tulsa Fire Department, we can’t do it alone. And any other partner — replace that name — can’t do it alone,” Lemery said. “It really takes the collaboration and great vision.”

Tulsa’s Zero Overdose learning community is the nation’s first comprehensive overdose prevention program implemented at this scale. 

Only one other organization, Zero Overdose in New York, has created a similar program, likening overdose prevention to suicide prevention. New York’s program, which has been operating since 2017, focuses on two of the framework’s seven elements: overdose risk screening and overdose safety planning. 

Tom McCarry, co-founder of Zero Overdose in New York, has worked closely with Healthy Minds on Tulsa’s overdose prevention initiatives. McCarry led a Zero Overdose learning community session about how organizations can implement overdose risk screenings and safety planning with the people they serve.

“Historically, we have worked most extensively with treatment organizations, but we have a vision of ‘zero overdose communities,’” McCarry said. “[Tulsa’s learning community] was a really exciting kind of window into how that could develop.” 

Oklahoma’s increase in overdoses

The launch of Tulsa’s Zero Overdose community comes at a time when overdose deaths in Oklahoma are increasing, driven mainly by a rise in meth-related overdoses.

Nearly two-thirds of Oklahoma’s unintentional overdose deaths in 2020 involved methamphetamine, according to data from the Oklahoma State Department of Health.

Overdose deaths by drug in Oklahoma, rate per 100,000 population

In Tulsa County, methamphetamine-involved overdose death rates have increased by more than 500% since 2012. In recent years, Tulsa County’s methamphetamine-involved overdose death rates have exceeded those of Oklahoma County, Oklahoma state, and the United States.

Co-use of methamphetamine and opioids — both intentionally and unintentionally — is also on the rise in Oklahoma, fueling the fourth wave of the opioid epidemic.

Tulsa County especially has felt the impact of co-use of these drugs — about a third of meth-related overdose deaths in 2020 were associated with an opioid, a higher percentage than in Oklahoma County or statewide. 

Percentage of meth-related overdose deaths associated with an opioid

People have reported many reasons for co-using opioids with methamphetamine, including synergistic effects, managing the symptoms of opioid withdrawal, and reducing risk of an opioid overdose. However, co-use of opioids and methamphetamine actually increases overdose risk, as the effects of one drug might mask the effects of the other. People who co-use also often have greater difficulty accessing treatment for substance use and are less likely to receive medication assisted treatment for opioid use disorder. Unintentional co-use can happen when methamphetamine is mixed with an opioid, usually fentanyl, without the user’s knowledge.

Certain Tulsa areas have seen higher numbers of methamphetamine-involved overdose deaths, including the zip codes that contain the Tulsa International Airport, the Dawson neighborhood, the Osage Casino, and the Gilcrease Museum. 

This map shows meth-related overdose deaths in Tulsa County from 2017 to 2021​. Source: Oklahoma State Department of Health, Injury Prevention Service, Fatal Unintentional Poisoning System​

To stem this rise in methamphetamine overdose deaths and to respond to the increase in demand for meth treatment use, Healthy Minds launched the Tulsa Methamphetamine Treatment Continuum in 2020, a working group made up of local nonprofits, state and community leaders, first responder agencies, and substance use experts. 

The treatment continuum’s steering committee identified three core objectives for Tulsa: increasing the availability of methamphetamine-specific treatment, implementing contingency management in substance use treatment facilities, and increasing overdose prevention practices. Zero Overdose was born out of the committee members’ commitment to adjust their organizational approach to overdose.

Putting Zero Overdose into practice

Zero Overdose employs a “champion” model to amplify its impact: participants attend learning sessions and bring back what they’ve learned to their organizations and colleagues. Ideally, those conversations then turn into meaningful policy and practice changes within those organizations to eliminate overdose deaths.

“If I can take the information that I learned through that group and get that to my crews [of 750 firefighters], then we’re making everybody in our community smarter and we’re able to multiply at a lot faster rate,” Lemery said.

The champions who attended Zero Overdose participated in four 90-minute, virtual sessions during which they learned about and discussed the seven-element framework, harm reduction, and data collection and evaluation. Participants also completed organizational self-assessments to measure their respective organizations’ readiness to incorporate the Zero Overdose framework. 

Already, organizations that participated in the Zero Overdose learning community sessions have started implementing what they learned into their everyday practices. 

At GRAND, there’s a renewed focus on harm reduction practices being incorporated into their treatment curriculum and new hire training with Healthy Minds’ guidance, Hill-Crowell said. GRAND has also made adjustments to how the agency collects and tracks data — a key element of the Zero Overdose framework — both at the Addiction Recovery Center in Tulsa and across the entire agency, which serves more than 16,000 Oklahomans in 13 counties.

Beyond the learning community, Healthy Minds and the treatment continuum’s steering committee are working on other initiatives to realize a zero overdose vision for Tulsa. 

Tulsa Fire Station 17, in zip code 74115, will soon be equipped with a harm reduction box where community members can access supplies like naloxone and fentanyl test strips. There were 34 meth-related overdose deaths in 74115 between 2017 and 2021.

With Healthy Minds’ help, GRAND secured new funding to increase outreach in Tulsa zip codes with the highest number of overdose deaths, which will allow GRAND to have an additional 1,000 outreach encounters in the next year.

Soon, Tulsa fire stations in three high-need areas will be equipped with harm reduction boxes, where community members can anonymously access free naloxone for reversing overdoses, fentanyl test strips for testing their drugs, and educational materials about safer use and treatment options. 

Preventing overdoses — not just responding to them — will remain a key focus for the Tulsa Fire Department, where leaders continue to increase their mental health and overdose approaches with practices informed by the Zero Overdose learning community.

“We want to aggressively keep moving forward and not become stagnant,” Lemery said. “However we can save lives, we want to do it.”

This report was authored by Emily McPherson, a 2022-2023 Healthy Minds fellow. The fellowship is made possible by The Anne and Henry Zarrow Foundation.

To learn more about the fellowship, visit healthymindspolicy.org/fellowship.