How Puerto Rico's Geographic Approach to Opioid Misuse Allows It to Save More Lives

In the late 1990s, pharmaceutical companies reassured the medical community that patients would not become addicted to opioid pain relief medications. Health-care providers then began to confidently prescribe opioid medications at a greater rate. Fast-forward to 2017, when an increase in prescription opioids resulted in the widespread misuse of both prescription and nonprescription opioids, leading the US Department of Health and Human Services to declare the opioid crisis a public health emergency.

Today an average of 100 Americans die every day from opioid overdoses. In Puerto Rico, the drug crisis is a bit more severe; according to the National Library of Medicine, the drug overdose mortality rate was significantly higher for Puerto Ricans than non-Hispanic white individuals (28.7 vs. 26.2 per 100,000, respectively). The 2018 drug overdose mortality rate was highest among Puerto Rican men aged 45–54, providing evidence of health disparity.

To tackle this widespread issue, the Puerto Rico Department of Health is emphasizing a geographic approach to address the epidemic and allocate resources to where they are needed most. By securing Centers for Disease Control and Prevention (CDC) funding through the Overdose Data to Action project, the department was able to design and implement syndromic drug misuse surveillance using geographic information system (GIS) technology, setting an example for others to follow. 

Puerto Rico's opioid misuse response centers on collecting and monitoring data of overdose survivors. Rather than tracking overdose deaths, the Department of Health aims to focus on preventing deaths by allocating additional resources. To understand what is taking place at the neighborhood level, the department needed to collect data but realized that there was no streamlined process for drug misuse data collection.

Local nonprofits on the islands were doing their best to outreach and allocate resources to the areas that they believed had the greatest number of residents afflicted with opioid addiction. However, due to the lack of a standardized data collection process, these efforts were not entirely accurate.

To modernize its approach, the Department of Health turned to ArcGIS Survey123 and created the Puerto Rico Overdose Surveillance System to collect this data in a standardized way. It deployed a form-centric solution, which allows the collection of data via web or mobile devices, even when disconnected from the internet. Staff from the department and cooperating agencies can go into neighborhoods to collect data in real time and upload it to one central location. Because the state government could not combat this crisis on its own, the Department of Health partnered with local nonprofit organizations and community clinics and is looking to collaborate with several other local government agencies across the islands as well.

"It has been very challenging to work with local nonprofits, the public health department, and other state departments within Puerto Rico due to this lack of a standardized data collection process," said Francisco Negrón Alemón, GIS programmer, Puerto Rico Department of Health. "But this solution has made this much easier and possible."

The department is currently working with the following organizations to collect data:

·       Intercambios Puerto Rico, Fajardo/Exchanges Puerto Rico

·       Iniciativa Comunitaria, San Juan/Community Initiative

·       El Punto en la Montaña, San Juan/The Point on the Mountain

·       Coalicion de Coaliciones, Ponce/Coalition of Coalitions

All these nonprofit organizations offer services to individuals who suffer from substance use disorders or homelessness or lack basic health care.

Through these unique collaborations, the Department of Health can gain greater insight into this problem and keep track of the combined efforts with the use of GIS technology.

An example of this collaboration is with the nongovernmental organization (NGO), Intercambios Puerto Rico (translated to English, it means Exchanges Puerto Rico), which has multiple programs addressing drug misuse. One of these, La Móvil, provides a vehicle that brings health services to areas where people have the greatest need. Intercambios Puerto Rico considers the fact that less than 10 percent of people at risk for problematic drug use, mental health problems, or other situations receive the health care they need. With La Móvil, staff use their experience in nursing, psychology, case management, and other disciplines to provide primary services and other support.

Access to the field data collected using ArcGIS Survey123 allows NGOs like Intercambios Puerto Rico to continuously track changing community dynamics and eventually monitor the success of their prevention and response tactics to ensure ongoing success. For the Department of Health, this initiative has a unique perspective due to its bottom-up nature, which presents a significant opportunity to learn from the experience and needs of the community. This collected data enables the development of guides to design, plan, and implement responsive, effective social programs. 

Equipped with Survey123, these teams head into areas that might be known for illegal drug use. There, they survey individuals who have suffered an overdose or those who have witnessed an overdose event, such as bystanders, first responders, and correctional officers.

The biopsychosocial questionnaire, which aims to determine how a person's biological, social, and psychological factors all influence their well-being, first identifies the individual as a survivor or a witness. It then leads into five parts of the survey, which ask a series of questions that allow the Department of Health to identify risk and protection factors that are related to substance use and overdose.

The following are questions from the survey:

·       Which substance did you consume that could have caused the overdose?

·       Was the most recent overdose reversed with naloxone?

·       Before starting substance use, were you a victim of violence?

·       How were you introduced to opioids?

·       Have you ever used fentanyl?

Survey results are immediately uploaded into the ArcGIS system. Local nonprofits have access to the data collected; they can create dashboards and then analyze the results. From their findings, they can then allocate resources to the areas the survey results show as being affected the most by the epidemic. 

Allowing local organizations access to this data in real time is merely the first step in this project. With the information from the survey results, the Department of Health is in the process of creating an opioid consumer profile. This will provide it with a greater, more detailed understanding of the individuals affected by the opioid misuse epidemic.

Puerto Rico's Department of Health hopes to expand its collaboration efforts to include local governments, hospitals, and emergency responders across the islands to allow for better data integration. Information can then be used to influence public policy, leading to administrative legislation that can address the crisis in Puerto Rico. With more partnerships, the department is also looking to create a public-facing dashboard, the Puerto Rico Opioid Dashboard, that will contain collected data so more agencies can utilize the information to better respond to the epidemic.

Using GIS, Puerto Rico's Department of Health can develop strategies that will effectively reach more people with substance use disorders and provide them with the care and resources they need.