additional resources for county coalitions - overdosefreepa · the spf details five steps that...

Additional Resources for County Coalitions

By:

Janice Pringle, PhD

PA Heroin Overdose Prevention TAC

University of Pittsburgh, School of Pharmacy Program Evaluation Research Unit (PERU)

July 2016

1 Copyright 2016. University of Pittsburgh. All Rights Reserved.

Agenda:

Introductions (15 minutes) TAC Staff and coalition members. Overview of PA Heroin Overdose Prevention TAC (15 minutes)

Goals:

1. Expand the OverdoseFreePA website to a statewide resource (demonstrate).

2. Provide technical assistance to county stakeholders as they build a community-based coalition and develop a targeted, evidence-based strategic plan to address the overdose epidemic.

3. Provide ongoing concierge assistance to coalitions as they implement their strategic plans.

Follow SAMHSA Strategic Prevention Framework

1. Assessment (60 minutes)

2. Capacity (60 minutes)

3. Planning (60 minutes)

a. Choosing Intervention Strategies (60 minutes)

b. Frameworks for Law Enforcement “Warm Hand-offs” (30 minutes)

4. Implementation (30 minutes)

5. Evaluation (15 minutes)

6. Sustainability & Inclusion (15 minutes)


Contents

A. Frameworks ..................................................................................................................................................................... 1

A.1 SAMHSA Strategic Prevention Framework ...................................................................................................... 1

A.2 Institute of Medicine (IOM) Protractor .............................................................................................................. 2

A.3 Innovation Framework and Organizational Health ...................................................................................... 4

B. Assessment ....................................................................................................................................................................... 5

B.1 Nature and Scope of the Opioid Epidemic ........................................................................................................ 6

B.2 Situation Assessment ................................................................................................................................................ 9

C. Capacity ............................................................................................................................................................................ 12

C.1 Coalition Development............................................................................................................................................ 12

D. Planning ........................................................................................................................................................................... 15

D.1 Developing a Plan ..................................................................................................................................................... 15

D.2 Choosing Intervention Strategies ....................................................................................................................... 17

E. Implementation ................................................................................................................................................................. 38

E.1 Implementation of Strategic Plan ....................................................................................................................... 38

F. Evaluation ............................................................................................................................................................................ 38

F.1 Evaluation of Strategic Plan .................................................................................................................................. 38

G. Sustainability ................................................................................................................................................................. 39

G.1 Sustaining Coalition and Relationships ........................................................................................................... 39


A. Frameworks

A.1 SAMHSA Strategic Prevention Framework

The Strategic Prevention Framework (SPF) was developed by the Substance Abuse and Mental

Health Services Administration (SAMHSA) and serves as a resource to plan prevention strategies for

substance use disorders (SUD) and overdoses. The SPF contains five steps and two guiding principles

to help communities address SUDs and related behavioral and health consequences.

The SPF details five steps that coalitions can follow as they progress through the process of

establishing programs to reduce overdose deaths in their communities. The five steps are explained

below:

1. Assess Needs: In order to effectively establish programs, county coalitions should assess

their communities’ needs. An important component of the needs assessment process is

gathering appropriate data to accurately identify the problem in the community. County

coalitions should be sure to engage stakeholders throughout the needs assessment process.

This will serve to ensure buy-in from stakeholders, while also gaining their support for

sustainability efforts.

2. Build Capacity: County coalitions should identify resources and readiness as early as

possible in the planning process. Engaging stakeholders is an essential component of building

capacity. Well-supported programs are more likely to succeed because more resources are

available and the community is prepared. Available resources and community readiness can

be increased by raising awareness of the issue that you would like to address and establishing

or strengthening community collaborations. Resources can include: grants or donations,

program promotion or advertising outreach, donated meeting spaces, food, computer hardware, and local champions who will support the efforts of the coalition.

3. Plan: Effective planning is crucial to the success and sustainability of county coalitions.

Planning ensures that coalition members and community stakeholders are on the same page

and working towards the same goal. Selecting appropriate interventions is a key step in the

planning process. The information gathered from the needs assessment should be used to

guide the selection of an intervention. Furthermore, the intervention should be evidence-

based and a good conceptual and practical fit for your community. Keep all coalition members

and stakeholders involved so that they remain committed to the program and vision.


4. Implement: Coalitions then implement the selected intervention. Coalition members should

work together to develop an action plan. The action plan should be a detailed, written

document that lays out exactly how the intervention will be implemented within the

community. The action plan should describe what is expected to be accomplished, specific

steps that will be taken to reach the goal, and who is responsible for each step. As

implementation progresses, the action plan should be adapted as needed.

5. Evaluate: Evaluation helps to quantify the challenges and successes of the program.

Evaluation is defined as “the systematic collection and analysis of information about program

activities, characteristics, and outcomes”. The information collected during the evaluation

step should be used to improve the effectiveness of the program. Furthermore, this

information should be shared with all coalition members and community stakeholders.

Results from evaluations can also be used to secure additional funding, increase public

interest, and, in some cases, decide whether or not the program should be continued.

In addition to the five steps, the SPF utilizes two guiding principles: sustainability and cultural

competence.

1. Sustainability: The goal of every coalition is achieving and maintaining long-term results.

Planning for sustainability should begin as early as possible because this is an ongoing

process that will be evaluated and revised as the coalitions move through planning,

implementation and evaluation. Sustainability involves building support among stakeholders

and community members, monitoring and showing results, and obtaining funding.

2. Cultural competence: Interacting with people of different cultures helps to ensure that coalition members meet the needs of all community members. County coalitions should practice cultural competence throughout the planning process in order to develop appropriate interventions and strategies (such as creating materials in additional languages) for their communities.

A.2 Institute of Medicine (IOM) Protractor


The IOM protractor is a tool that is used to conceptualize prevention in the behavioral health field.

The model should be used to effectively develop and provide prevention services to diverse

populations.

1. Promotion

a. Health promotion refers to intervention efforts that target the general public or the whole

population.

2. Prevention

a. Universal prevention refers to interventions that target the general population rather

than an identified individual risk. Examples of universal prevention include school-wide

substance use prevention programs and community media campaigns.

b. Selective prevention efforts target individuals or a population subgroup whose risk for

developing a mental health disorder or SUD is significantly higher than average. An

example of an intervention would be an alcohol dependence prevention course that

targets 11th graders because they are at higher risk.

c. Indicated prevention efforts target populations that are identified on the basis of

individual risk factors or initiation behaviors that put them at high risk for developing

SUDs. An example of an indicated prevention effort would be alcohol dependence classes

for individuals who initiated binge drinking and are at an increased risk of developing an

alcohol use disorder.

3. Treatment

a. Once an individual has developed a mental health disorder or SUD, then prevention

efforts are no longer adequate for this individual and treatment is needed.

b. Case identification refers to the diagnostic process by which an individual is officially

diagnosed. An example of case identification would be using Screening, Brief

Intervention, and Referral to Treatment (SBIRT) to identify individuals with problem

alcohol or substance use and connecting them with a professional who can officially

diagnose (or not diagnose) them with an SUD.

c. Treatment involves the active intervention of a professional who can work with

individuals to address their particular needs. An example of treatment would be

Medication Assisted Treatment with psychosocial counseling to help an individual who is

struggling with an opioid or alcohol use disorder.

4. Maintenance

a. Maintenance involves helping an individual maintain mental health and/or sobriety. An

example would be recovery support services to help an individual with an opioid use

disorder maintain sobriety. These services can include sober living environments,

Alcoholics Anonymous (AA) Narcotics Anonymous (NA) meetings, or continuing

psychosocial counseling.


A.3 Innovation Framework and Organizational Health

The System Transformation Framework is used to develop and enhance the effectiveness of an

organization in order to maximize its ability to achieve its selected purpose.

1. Using the System Transformation Framework

a. The Framework is intended to provide a guide to system transformation around one

domain: the Vision or greater purpose of the organization.

b. This domain influences four other domains regarding the function of the organization:

i. Culture - or employee/members’ values, beliefs and assumptions about their work;

ii. Behavior - or how employees/members’ handle relationships, power, decision-

making, conflict, and learning;

iii. Structure - or how the organization is designed so lines of communication in the

organization can facilitate decisions and innovations; and

iv. Performance Measurements - for system improvement.

c. These domains are continually managed by the facility leadership.

d. All domains are influenced by:

i. External learning - methods to provide learning and skills development to the

workforce); and

ii. Internal learning - systematic processes used to improve organizational functioning,

which can continuously transform the organization towards its intended vision).

2. Levers

a. Vision: the “ideal” or “True North” of an organization. It is the lens that guides all work conducted by the organization.

b. Leadership: agents within the system who see their role to provide resources and tools

to others so they may continuously meet the organization’s vision every day. i. Types of Leaders

1. Formal Leaders have titles and persons who report to them.

2. Informal leaders lead a group of people through their opinions and beliefs.

3. Servant leaders work for those he/she supervises to ensure they have what they need to perform optimally and align with the Vision.

4. Every person leads him or herself.

i. Role of a leader is to: 1. Provide each person with the tools and resources to create meaning;


2. Recognize that meaning when it is developed;

3. Ensure that all persons are treated with dignity and respect; and

4. Reinforce the Vision and all it does.

c. Organizational Culture: the attitudes, values, beliefs, and assumptions among agents that

affect HOW work is done.

d. Organizational Behavior: The manner in which the system behaves across 5 domains: i. Relationships: Do the interactions among various parts of the system generate energy

and innovative ideas for change or do they drain the organization?

ii. Decision-making: Are decisions about change made rapidly and by the people with the most knowledge of the issue, or is the change bogged down in the hierarchy and position-authority?

iii. Power: Do individuals and groups acquire and exercise power in positive constructive ways towards a collective purpose, or is power coveted and used mainly for self-interest?

iv. Conflict: Are conflicts and differences of opinion embraced as opportunities to discover new ways of working, or are these seen as negative and destructive?

v. Learning: Is the system naturally curious and eager to learn more about itself and about what might be better, or is new thinking viewed mainly as potentially risky and threatening to the status quo?

e. Performance Measurement: Meaningful information that is collected within the course of the agents’ work that can be used by the internal learning system to determine how to best meet the system’s Vision.

f. Organizational Structure: The manner in which the system is structured so that optimal communication and innovation can occur among its agents.

g. Internal Learning System: The systematic method of using performance measurement data to learn HOW to move towards the organizational Vision (Six Sigma and Lean are two examples of Internal Learning).

h. External Learning System: The identification of exactly what new knowledge or skills the system needs to learn or acquire to address a specific performance gap and pulling only that new knowledge or skill into the system at the point when it is needed using learning principles that potentiate the knowledge/skill uptake by the targeted system agent.

B. Assessment

(60 minutes) Objectives: Describe the incidence of overdose in the US and Pennsylvania; Distinguish between opioid and non-opioid medications and drugs;


Identify risk factors and intervening variables that place groups at high risk for overdose death; Develop a community profile for the local county; Assess community readiness using a measurement instrument; and Use data sources to determine overdose incidence in a geographic area/county.

B.1 Nature and Scope of the Opioid Epidemic

1. Incidence a. In 2014, 47,055 people died from overdose in the United States.

b. In 2014, 2,732 people died from overdose in Pennsylvania (approx. 7/day) (CDC, 2015).

c. The overdose death rate in PA for 2014 was 18.9 per 100,000 people, the 8th highest rate

in the US (US rate 14.7).

d. PA was one of 14 US states with a statistically significant increase in its overdose death rate from 2013-2014.

e. In 2014, opioids (including heroin) contributed to 61% of all drug-poisoning deaths. Additionally, oxycodone and hydrocodone were involved in more overdose deaths than any other type of opioid (Rudd, Aleshire, Zibbell, & Gladden, 2016).

2. What are opioids?

a. Opioids are compounds that bind to opioid receptors in the brain. Opioids include semi-

synthetic, which are opioids that are synthesized from naturally occurring opiates (e.g.

heroin from morphine), and synthetic opioids such as methadone and fentanyl

(Rosenblum, Marsch, Joseph, & Portenoy, 2008).

b. The opioid receptors involved in pain sensation are located in the central and peripheral

nervous systems. The receptors are also involved in the reward functions of the brain.

c. There are multiple opioid receptors (e.g. mu, kappa, and delta), but opioid drugs most often produce their pain relieving and reinforcing effects through the activation of the mu

opioid receptor (Rosenblum et al., 2008). Drugs that have the ability to fully activate the

opioid receptor are called agonists (e.g. morphine, oxycodone). Antagonists are classified

as drugs that occupy the opioid receptor, but do not activate the receptor (e.g. naloxone,

naltrexone). These block the receptors and prevent opioids from binding and having an

effect.

d. Drugs that are pure opioid agonists can produce clinical dependence and tolerance with

short or long-term use.

e. Prescription Opioids

i. Prescription opioids are sometimes referred to as “prescription opioid analgesics”

and include drugs such as oxycodone (OxyContin®), morphine, hydrocodone

(Leonard J Paulozzi & Yongli Xi, 2008).

ii. Historically, these medications were used to treat cancer and end-of-life pain because

of the fears of addiction. However, beginning in the 1980’s, physicians began


aggressively treating chronic pain (i.e. “pain as the fifth vital sign”) with opioid

analgesics, essentially disregarding the potential for addiction in favor of increasing

patient satisfaction and effective pain management (L. J. Paulozzi & Y. Xi, 2008;

Rosenblum et al., 2008).

iii. Deaths related to opioid analgesic overdoses began increasing in the early 21st

century (Calcaterra, Glanz, & Binswanger, 2013).

iv. Prescription drug monitoring programs (PDMPs) and drug reformulations were

established to combat the increasing numbers of deaths related to prescription

opioids. However, as the number of prescription opioid deaths began to decrease, the

number of deaths related to heroin also began to rise.

f. Heroin

i. Heroin is a drug that is synthesized from morphine and is highly addictive. After it

enters into the brain it is converted back into morphine and binds to opioid receptors

in the brain (Indivior Inc., 2015).

ii. Heroin can either be injected, inhaled (i.e. snorted or sniffed), or smoked. It is typically

sold as a white or brown powder, or a sticky brown substance, which is known as

“black tar heroin” (Drug Enforcement Agency (n.d.)) Most powder heroin is rarely

pure and is typically “cut” with substances such as sugar or starch. However, cases of

heroin cut with the potent analgesic fentanyl have been increasing.

iii. Most heroin is processed from poppy plants that are grown in Southeast and

Southwest Asia (Laos, Thailand, Pakistan, and Afghanistan), Mexico, and Colombia

(Drug Enforcement Agency (n.d.)).

iv. Heroin overdoses have more than tripled since 2010 (Rudd et al., 2016).

g. The rising problem of fentanyl: i. Fentanyl is a synthetic opioid that is more powerful than morphine. It is typically

prescribed for people who experience severe pain or who have a tolerance for other opioids (National Institute on Drug Abuse, 2012).

ii. When fentanyl is prescribed by a physician, it is typically administered via injection, a patch that is worn on the skin, or in lozenge form (National Institute on Drug Abuse, 2012).

iii. Illicit fentanyl has recently been involved in a growing number of overdose deaths. It is typically mixed in with street heroin, making the heroin far more potent and deadly.

iv. Illicit fentanyl is often manufactured in illegal labs.

h. Synthetic or “Research” Chemicals – not scheduled: i. W-18

ii. U-47700


iii. Chemical analogs

3. Connections between prescription opioids and heroin a. There is research that confirms a link between prescription opioid use and overdose and

the increase in heroin use and overdose. b. As mortality from prescription opioids increased, measures were taken to reduce the

incidence of dependence and overdose. These measures included the introduction of PDMPs and the reformulation of OxyContin. Following these measures, the rates of prescription opioid overdoses did decrease (Longo, Compton, Jones, & Baldwin, 2016).

c. However, the decreasing rates of fatal overdoses attributed to prescription opioids

opened the door to increasing rates of heroin useand overdoses. It is not clear why this exists, but some research postulates that making prescription opioids increasingly expensive and unavailable has encouraged users to switch to heroin, which is easier to get and much cheaper.

d. Research has shown that individuals who initiate heroin use are more likely to report

past non-medical use of prescription opioids (Jones, 2013; Longo et al., 2016).

4. The role of the community coalition in addressing the opioid epidemic and reducing

overdose deaths.

a. Community coalitions can utilize a multi-disciplinary approach to reducing opioid

overdose deaths. Coalitions can include individuals from multiple entities that are

involved in SUD services and have special interest in the current opioid overdose

epidemic.

b. Coalitions may include individuals from: law enforcement and criminal justice agencies,

Single County Authorities (SCAs), emergency medical personnel (i.e. EMS, paramedics,

firefighters), drug and alcohol treatment agencies, medical associations or other

prescriber groups, representatives from community-based organizations which may

include harm reduction agencies, social service agencies, SUD support groups, political or

business leaders, and individuals from the local community that may have first-hand

experience with substance use (i.e. people who use drugs, people who are in recovery,

families or friends of individuals who use drugs and/or have died from an overdose

caused by opioids).

c. These coalitions can be influential in identifying the demographics of the community, the

scope of the opioid problem, and which intervention strategies may be the most useful in

lessening the burden of the problem, specifically tailored to the needs of the community.

d. Benefits of forming a community coalition include (Community Catalyst, 2003; U.S. Department of Housing and Urban Development, 2009): i. Increased effectiveness, efficiency, and community voice;

ii. Maximizes community resources and eliminates duplication of services;

iii. Enhanced legitimacy and political clout within the community;


iv. Improved communication, data sharing, organization, and working relationships

within the community; and

v. Increased funding base and enhanced networking opportunities.

B.2 Situation Assessment

1. Defining your county/community a. In order to effectively select an intervention, it is vital that the coalition understand the

demographics and needs of their specific community. The results of the assessment will be crucial to choosing appropriate evidence-based interventions.

b. Coalitions should consider some specific community factors: i. Culture factors including political leanings and religion/spirituality;

ii. Economic factors including income levels, and unemployment rates;

iii. Social factors including social networks and socialization patterns;

iv. Power structures including the power distribution across the local community;

v. Demographic factors including racial/ethnic makeup and age distribution; and

vi. The community’s prior interaction with other groups with the goal of reducing opioid

overdoses.

c. Other factors to consider include:

i. Number of overdose deaths within the county;

ii. Locations where most overdoses occur; and

iii. Available SUD treatment resources.

d. Complete the “Defining Your Community” worksheet in the TAC Manual to identify community factors for your specific county.

2. Obtaining data a. In order to have a greater understanding of the opioid overdose epidemic, coalitions

should review national, state, and local data.

b. National data sources can be helpful to communities who may not have a broad awareness about the opioid epidemic in America. Some of these sources include:

i. The Centers for Disease Control and Prevention (CDC) is a great source for national

level data. Additionally, data from years’ past can be obtained, which can be useful for communities wishing to study and understand the trends in opioid use and overdose. Data can be retrieved from http://www.cdc.gov/drugoverdose/.

http://www.cdc.gov/drugoverdose/


ii. SAMHSA provides a report that outlines the results from the National Survey on Drug Use and Health (NSDUH) which is a survey on alcohol, tobacco, and illegal drug use for individuals aged 12 and older in the United States. Communities may find this information helpful in establishing trends in drug dependence. Data can be retrieved from http://www.samhsa.gov/data/population-data-nsduh.

c. State data is another key piece of information for communities who wish to develop coalitions. Pennsylvania data sources include: i. The CDC has state overdose death data available on its website (see link above).

ii. The Pennsylvania Department of Drug and Alcohol Programs (DDAP) publishes reports about drug overdose deaths. DDAP also provides information about opioid overdose and treatment resources throughout the state. DDAP can be accessed via the following link: http://www.ddap.pa.gov/pages/default.aspx.

iii. The Pennsylvania Department of Health (DOH) publishes a report that details each

county with regards to various health statistic measures. This can be useful to coalitions as they conduct their community assessments. The 2015 report can be retrieved from:

http://www.statistics.health.pa.gov/HealthStatistics/VitalStatistics/CountyHealthProfiles/Pages/CountyHealthProfiles.aspx#.VyzgXChWZ8F.

iv. The DEA Philadelphia Division reports drug overdose deaths for Pennsylvania. This

is available from http://www.dea.gov/divisions/contacts/phi_contact.shtml.

v. The Pennsylvania Coroners Association releases a report on overdose death statistics. The report contains information from each county and can be retrieved from

http://www.pacoroners.org/index.php.

d. Local data is another key piece of information that is important for communities as they

begin to develop their coalitions.

i. OverdoseFreePA is a website that provides overdose death data for participating counties throughout the Commonwealth. OverdoseFreePA can be accessed via http://overdosefreepa.org/.

ii. Counties that do not currently submit data to OverdoseFreePA are encouraged to do so in collaboration with their coroner or Medical Examiner.

iii. Other data may be available from local EMS, EDs, law enforcement agencies, etc.

iv. In addition to overdose death data, OverdoseFreePA provides resources and educational information for the following focus areas: 1. Criminal Justice; 2. Family and Friends;

3. Healthcare Professionals; and 4. School and Work Leaders.

http://www.samhsa.gov/data/population-data-nsduh

http://www.ddap.pa.gov/pages/default.aspx

http://www.statistics.health.pa.gov/HealthStatistics/VitalStatistics/CountyHealthProfiles/Pages/CountyHealthProfiles.aspx#.VyzgXChWZ8F

http://www.statistics.health.pa.gov/HealthStatistics/VitalStatistics/CountyHealthProfiles/Pages/CountyHealthProfiles.aspx#.VyzgXChWZ8F

http://www.dea.gov/divisions/contacts/phi_contact.shtml

http://www.pacoroners.org/index.php

http://overdosefreepa.org/


v. Interactive features on OverdoseFreePA include: 1. Naloxone finder for pharmacies which carry naloxone; 2. Treatment finder for MAT programs in PA; 3. Prescription drug take back box locater; 4. An “Emergency” button with procedures for a suspected overdose emergency; 5. Events calendar; and

6. Speaker’s bureau.

e. Additional data sources are listed in the “Potential Sources of Data” appendix in the TAC Manual.

3. Intervening variables/risk factors for high risk populations: a. Risk factors for overdose (Substance Abuse and Mental Health Services Administration,

2016): i. Polysubstance use (i.e. heroin with benzodiazepines);

ii. Individuals with preexisting medical conditions—respiratory illnesses, HIV, Hepatitis

C;

iii. Prior overdose experience;

iv. Opioids for chronic pain and long-term opioid use for pain management; and

v. Release from incarceration, detoxification programs, and treatment programs.

b. High risk populations include: i. Incarcerated populations;

ii. Individuals with co-occurring mental health disorders and SUDs, which increases

chances of polysubstance use; and

iii. Individuals with preexisting physical illnesses (i.e. respiratory illness, HIV, Hepatitis C).

c. Subpopulations most affected by overdose: i. Communities should be aware of what populations are experiencing a greater burden

of SUDs and overdose.

ii. Demographics

d. Problem drugs and routes of administration:

i. Communities should be aware of what drugs are the most problematic locally -

heroin, prescription opioids, fentanyl, cocaine, alcohol, etc.;

ii. Communities should also have an understanding of how people are consuming drugs—injection, snorting, smoking, or swallowing.


e. Community settings for overdose: i. Coalitions should be aware of where overdoses are occurring. What geographic

areas?

ii. Are overdoses occurring in private residences, in public areas, along traffic corridors?

4. Community readiness: a. The TAC will guide a coalition through a “Community Readiness Assessment” to gauge

the community’s current state of readiness to address overdose deaths.

b. Communities with lower readiness levels should increase awareness and readiness before planning intervention strategies.

c. Communities with higher readiness levels can increase awareness and begin to plan

intervention strategies.

d. After completing the “Community Readiness Assessment” worksheet in the TAC Manual, compare your county’s level of readiness to the “Stages of Community Readiness” in the

TAC Manual to determine where your county coalition should begin its efforts.

e. Communities with lower levels of readiness should initially focus on strategies to increase

awareness of overdose in the community and reduce stigma.

f. Communities with higher levels of readiness can begin to select intervention strategies.

5. Selecting the appropriate response/intervention:

a. Evidence-based practices (EBPs) include: i. Naloxone distribution and Medication Assisted Treatment; and

ii. Prescription Drug Monitoring Programs (PDMPs) and Prescribing Practices/Guidelines.

b. Mobilize the community to action.

C. Capacity

(60 minutes) Objectives: Identify domains that should be included in a community coalition to fight overdose deaths; Develop a vision statement for your community coalition; Design coalition leadership structure to meet needs of the organization; and Assess organizational health through use of surveys and instruments.

C.1 Coalition Development

1. Form or develop a county coalition to address overdose deaths.

2. Identify coalition members who represent appropriate domains (not all required):

a. Single County Authorities (SCAs);

b. Law Enforcement;


c. Coroner/Medical Examiner;

d. CJAB;

e. EMS;

f. Medical Society/Prescribers;

g. Corrections/Jail;

h. SUD Treatment Providers;

i. General Health Care Providers;

j. Specialty Health Care Providers;

k. Pharmacists/Dispensers;

l. Family/Friends;

m. Recovery Support;

n. Political Leaders;

o. Community Leaders;

p. Faith-based;

q. Schools/Colleges/Universities; and

r. Employers.

3. Ensure that your coalition reflects the community composition and is inclusive of

subgroups.

4. Identify coalition leaders:

a. Consider the background and experience of potential coalition leaders – ideally they will:

i. Have leadership experience;

ii. Be respected in community;

iii. Have access to community leaders;

iv. Understand issues of overdose;

v. Be a “Servant Leader”;

vi. Be open-minded.

b. Identify a smaller, core leadership group (steering group) from the larger coalition

membership.

5. Develop a Vision for your coalition:

a. Assemble the leadership group;

b. Determine the focus and scope of your coalition;

c. Determine the timeframe (usually 5 years for newer groups);

d. Determine an ideal vision/greater purpose for the future;


e. Draft a coalition vision/greater purpose that is:

i. Short;

ii. Easy to remember;

iii. Serves as a compass for the organization;

f. Obtain input of the full coalition membership regarding the vision;

g. Refine the vision/greater purpose as needed;

h. Share the formulation of the vision/greater purpose, including:

i. Why it is important;

ii. The process used to develop it;

iii. How it will be used by the coalition;

iv. How leaders will ensure it is used as intended;

v. The timeframe for the Vision; and

vi. The process that will be used to assess the extent to which the vision is achieved.

6. Conduct coalition meetings:

a. Identify meeting locations which are accessible to coalition members. Community

organizations or coalition member agencies may have meeting space available for use at

no cost, or a local business or restaurant may provide a meeting room for community

groups. Consider accessibility for those who represent key domains.

b. Plan agenda, format, and develop a timeline for meetings; and

c. Encourage participation and inclusion.

7. Coalitions that are more established should conduct a Coalition Health Assessment to

ensure optimal coalition function. TAC staff can help guide coalitions through this

assessment process using a proprietary framework. (The “Coalition Health

Assessment” is available in the TAC Manual). Assessment areas include:

a. Relationships;

b. Decision-making;

c. Power;

d. Conflict;


e. Learning;

f. Organizational Structure;

g. Performance Measurement;

h. Internal Learning; and

i. External Learning.

D. Planning

(60 minutes) Objectives: Apply community assessment data to build logic models for overdose prevention; Identify evidence-based intervention strategies to address overdose risks; Describe key components of evidence-based intervention strategies; and Match intervention strategies appropriate to risks identified in logic model.

D.1 Developing a Plan

1. Strategic plan: a. The development of a strategic plan should be completed once the needs of your

community have been assessed.

b. The “SMART” framework should be used to develop the strategic plan:

i. Specific- how much of a change you expect (%, number, etc.) based upon community readiness, resources, coalition influence;

ii. Measurable- data is available and will show an effect;

iii. Achievable- objectives are possible and your coalition can accomplish them;

iv. Relevant- objectives fit your group, community, and the issue you are targeting; and

v. Time-oriented- you have a timeline for when your objectives can be achieved.

2. Impact model:

a. An impact model (sometimes called a logic model) is a useful tool that can guide your coalition in the efforts to reduce overdoses.

b. The impact model provides a visual map of the work that your coalition plans to do and the effects that this work will have on the problem.

c. Explanations of the impact model terminology: i. Situation refers to the current condition that you are trying to address within your

community. This is obtained from the data on your overdose phenomena.

ii. Inputs include the people and resources available to your coalition and the


characteristics of your community. You will need to consider what strategies will fit into your community and capabilities, what resources are available to you and your community, and what barriers may impede the implementation of particular strategies.

iii. Activities refer to the actions and tools that will be used to implement your program. This portion of the impact model should contain products, services, and activities you have or can obtain to use in your efforts.

iv. Outputs are the products of your coalition efforts such as types, levels, and targets for your activities. Examples of outputs include the number of treatment centers available, people who participated in program activities, hours of programming, etc.

v. Outcomes are the specific and measurable behavior changes in knowledge, skills, or attitudes of those affected by your program. These can be changes in awareness, practices, knowledge, or relationships. Outcomes can be measured on a short-term, medium-term, or long-term basis.

vi. Impact is usually the longer-term goal (generally a few years or more) that occurs in the community as a result of your coalition’s efforts. Examples of impact can be policy changes or improved conditions that reduce overdose.

d. Complete the “Impact Model Worksheet” in the TAC Manual to develop an impact model for each of the situations your coalition would like to address.

3. Intervention model – Institute of Medicine “Protractor:”

a. Health promotion – health in all policies.

b. Prevention: i. Universal – targets broad populations regardless of specific risk;

ii. Selective – delivered to subpopulations with higher risk;

iii. Indicated – targets individuals to address specific risk conditions.

c. Treatment:

i. Case Identification – SBIRT;

ii. Treatment – MAT.

d. Maintenance: i. Recovery support;

ii. Relapse prevention;

iii. After care/rehabilitation.

4. Choosing intervention strategies:

a. When choosing an evidence-based intervention for your community, it is important to consider conceptual fit (does the strategy address the identified problem) and practical


fit (is the strategy a good match for the characteristics of your community).

b. Coalitions should choose intervention strategies from the four evidence-based practice areas below (EBPs): i. Naloxone Availability;

ii. Medication Assisted Treatment;

iii. Opioid Prescribing Practices; and

iv. Prescription Drug Monitoring Programs.

D.2 Choosing Intervention Strategies

(60 minutes) 1. Naloxone (Narcan™) availability:

a. What is naloxone? i. Naloxone is an opioid antagonist and is used to reverse an opioid overdose. An

antagonist is a chemical entity that binds to a receptor and blocks its activation. Antagonists prevent the natural substance from activating its receptor.

ii. Naloxone is a safe medication and will only have an effect if an individual has opioids in their system. Specifically, naloxone will not be effective if someone has not taken opioids and cannot be used to reverse overdoses caused by other drugs such as cocaine, benzodiazepines, alcohol, methamphetamine, etc. However, if opioids are taken with other substances, naloxone can still help.

iii. Naloxone has no potential for dependence.

b. How does naloxone work to reverse an opioid overdose? i. When given to someone who has too many opioids in their system, naloxone displaces

existing opioids by binding to the opioid receptors in the brain (Hawk, Vaca, & D'Onofrio, 2015). Additionally, naloxone prevents additional opioids from occupying those receptors, which is why it is important that an individual who has just been given naloxone does not take any additional opioids (i.e. heroin or prescription opioids). Opioids taken after the administration of naloxone will not have an effect, but may put an individual back into an overdose once the naloxone has worn off.

ii. When naloxone is given to a person with opioids in their system, the naloxone will negate the effects of the opioids, meaning that an individual may experience withdrawal symptoms, including vomiting, chills, body aches, etc.

iii. Naloxone only works for 30 to 90 minutes, which means that an individual may slip back into an overdose, especially if that individual has long acting opioids in their system. Given this, it is important that emergency medical services (EMS) be notified, so the person can be transported to the hospital. If EMS personnel are not called, make sure that the person is not left alone for up to two hours following the administration of naloxone.

c. What formulations exist for naloxone (e.g. how can naloxone be administered to someone in an overdose situation)?


i. The Food and Drug Administration (FDA) currently approves naloxone for administration in three forms: intramuscular via syringe, intranasal, and intramuscular via auto-injector. It is common for these products to include TWO doses, in the event that one dose does not reverse the overdose.

ii. Intramuscular naloxone is the most common form and is administered via syringe into a muscle (i.e. thigh, upper arm or shoulder). This formulation has been used by medical personnel for decades and is commonly given out at community-based overdose education and naloxone distribution programs (OEND). This formulation is the least expensive out of the three formulations.

iii. Intranasal naloxone was recently approved by the FDA for use during an opioid overdose. This formulation is absorbed into the body via the nasal mucous membranes. Prior to this formulation with FDA approval, off label nasal naloxone was used, which required the assembly of a kit that included a syringe adapted to fit an atomizer, which was then placed into the nostril of the individual who was overdosing. The new FDA approved intranasal formulation does not require assembly and is already designed to be administered into each nostril. In an overdose situation, the person administering the nasal naloxone will mist half the dosage into one nostril and the other half into the other nostril. Intranasal naloxone is more expensive than the traditional intramuscular naloxone.

iv. Intramuscular via auto-injector (Evzio®) the FDA approved formulation is the Evzio® auto-injector. The auto-injector is similar to an EpiPen® and gives verbal, step-by-step directions to the person administering the naloxone. This formulation is given into a muscle (i.e. thigh, upper arm/shoulder) and is designed to be user friendly. Evzio® is the most expensive of the three FDA approved formulations.

d. Does insurance cover naloxone? i. Naloxone is generally covered by most insurance plans, including Medicaid and

Medicare. Copays will vary by insurance and the form of naloxone (i.e. intramuscular, intranasal, auto-injector) that is stocked and distributed by the pharmacy. People should check with their individual insurance plan to determine coverage and copays.

1. Naloxone Access: a. Where can someone get naloxone?

i. Act 139 and naloxone availability in pharmacies: 1. Act 139 was passed into law in Pennsylvania in November 2014. Among other

initiatives, Act 139 allowed for the standing order prescribing of naloxone (The Network for Public Health Law, 2014). A standing order is a written prescription by an authorized prescriber to make a medication available to those who meet pre-described conditions. Following the passage of this law, the PA Physician General signed a state-wide standing order for naloxone. This allows individuals to obtain naloxone from a participating pharmacy without having to see a physician. This helps to expand access to individuals, such as family members and friends, who may witness an overdose.

ii. Physicians: 1. Physicians are encouraged to co-prescribe naloxone to patients who use opioids

for acute or chronic pain, especially patients who are prescribed high dosages of


opioid medications (i.e. > 100 mg/day morphine equivalent, or MME) or those that are taking medications such as benzodiazepines or barbiturates.

2. Act 139 also established criminal and civil immunity for providers who prescribe, dispense, or distribute naloxone to someone who may witness an overdose (e.g. third party prescribing) (The Network for Public Health Law, 2014).

iii. Community-based opioid overdose education and naloxone distribution programs

(OEND): 2. Community-based OEND programs are one of the early adopters of naloxone

distribution. Some of these programs co-exist with needle or syringe exchanges and focus on education and distribution of naloxone to people who use drugs.

b. Who should have access to naloxone? i. Those at high risk of experiencing an opioid overdose (Baca & Grant, 2005; Maxwell,

2006); 1. People who use drugs (i.e. opioids including heroin).

a. People who use opioids are the most at-risk for experiencing an overdose, therefore it should be a priority to equip these individuals with naloxone (Bennett, Bell, Tomedi, Hulsey, & Kral, 2011). The social networks of people who use opioids typically include other drug users, meaning they are most likely to be present when an overdose occurs.

2. People who use drugs and are recently released from incarceration or SUD treatment. b. Incarceration and SUD treatment generally involve prolonged periods of

abstinence. Periods of abstinence decrease tolerance and make overdose much more likely if the individual returns to drug use. Additionally, many individuals who leave incarceration or SUD treatment return to their previous environments and social networks, which may include people who use drugs, and they may be likely to relapse. To reduce the risk of overdose due to decreased tolerance, coalitions can train individuals in overdose prevention and response, as well as distribute naloxone (Wakeman, Bowman, McKenzie, Jeronimo, & Rich, 2009)(Barocas, Baker, Hull, Stokes, & Westergaard, 2015; Lott & Rhodes, 2016).

3. People who take prescription opioids for acute or chronic pain.

4. Individuals who are co-prescribed opioids with other medications. a. It is important that people who are co-prescribed opioids and other

medications, such as benzodiazepines or barbiturates, understand the risks of taking these medications in combination.

b. Naloxone can be prescribed to these individuals with an opioid prescription.

ii. People who may witness an overdose include: 1. Friends and family members of people who use drugs (Doe-Simkins, Walley,

Epstein, & Moyer, 2009; Giglio, Li, & DiMaggio, 2015; Organization, 2014); and

2. Individuals who work in professions where they may encounter people who use


drugs (i.e. correctional officers, employees at SUD treatment centers).

iii. People who are likely to respond in an overdose situation (Banta-Green, Beletsky, Schoeppe, Coffin, & Kuszler, 2013; Ray, O’Donnell, & Kahre, 2015; Wagner et al., 2015): 1. Law enforcement officials, including police officers.

a. When 911 is called for an overdose, it is fairly common to have police officers arrive on the scene. In these situations, police officers should be equipped with naloxone for immediate administration. Waiting for EMS to arrive can be detrimental to health of the person overdosing and may result in permanent injury/disability or death.

2. Emergency Medical Services (EMS) personnel (i.e. paramedics, emergency

medical technicians (EMTs), Quick Response Services (QRS). a. Paramedics have been carrying and administering naloxone for decades; b. EMTs in PA have recently been permitted to administer naloxone. Training

and equipping EMTs and firefighters/QRS with naloxone will save lives, especially if they arrive first on scene.

3. Opioid Overdose Education and Naloxone Distribution Training (OEND) (Substance

Abuse and Mental Health Services Administration, 2016): a. What puts a person at risk of an overdose?

i. Recent incarceration or SUD treatment - decreased tolerance;

ii. Using opioids intravenously (IV);

iii. Being prescribed high dosages of prescription opioids (>100 MME);

iv. Previous overdose experience;

v. Taking opioids with other substances including alcohol and benzodiazepines; and

vi. Pre-existing medical conditions that affect respiratory, liver, and immune system function.

b. What happens during an opioid overdose?

i. Opioids act as central nervous system (CNS) depressants and bind to receptors in the brain, spinal cord, and gastrointestinal tract. Opioids serve to minimize the body’s perception of pain.

ii. When too many opioids enter the body, breathing slows and eventually stops altogether.

iii. Decreased oxygen to the brain and other body organs can cause permanent damage or even death.

c. What are the signs and symptoms of an overdose?

i. Person is not responding to painful stimuli or may be unconscious;


ii. Body is limp;

iii. Small, pinpoint pupils;

iv. Skin appears grey, along with blue/purple lips and fingernails;

v. Breathing is slow and shallow with slowed, erratic, or nonexistent heart rate; and

vi. Individuals may produce choking sounds or a snore-like gurgling noise.

d. What is the proper response in an overdose situation? i. Assess response - Sternal rub:

1. A sternal rub is done by rubbing knuckles of one hand on the sternum (breastbone) of the person suspected of overdosing. This produces a painful stimulus and may elicit a response.

2. These practices are not recommended: do not put the individual in a cold shower or ice bath; do not inject the individual with bleach, salt, or any other substance; do not induce vomiting.

ii. Call 911: 1. 911 should be called in an overdose situation so the person can be taken to the

hospital and medically monitored. However, many individuals are reluctant to call 911 due to fear of police involvement. Act 139 has established Good Samaritan clauses, which protect individuals who call 911, and the individual overdosing, from charge and prosecution for drug possession or drug paraphernalia. It is especially important to call 911 if naloxone is not available.

iii. Rescue breathing: 1. If the person’s breathing is slow (<10 breaths/minute) or absent, begin rescue

breathing. Breathing for someone may keep them alive until help arrives or naloxone can be administered.

iv. Administer naloxone (if available): 1. If naloxone is available, it should be administered to the person who is

overdosing. Once naloxone is administered, it may take a few minutes to work, meaning that rescue breathing should be continued. If the person does not respond in 3-5 minutes, administer a second dose of naloxone.

v. Stay with the person until help arrives: 1. Naloxone is only effective for 30-90 minutes, so it is imperative to monitor the

individual. If EMS are not called, make sure someone is with the person for up to two hours following the administration of naloxone.

2. The person may feel unwell after naloxone is given, but it is important that they not take any more opioids, as it may cause an overdose once the naloxone has worn off.

3. Since naloxone blocks the opioid receptors in the brain, taking additional opioids will not help to relieve withdrawal symptoms.


4. Medication Assisted Treatment

a. What is Medication Assisted Treatment? i. Medication Assisted Treatment (MAT) combines behavioral therapy and medications

to treat SUDs.

ii. MAT does not replace therapy; it is an adjunct to therapy, helping individuals to deal with the psychosocial issue of addiction.

iii. Including medication in treatment is one of the best choices for opioid addiction.

iv. When a person suffers from addiction, certain medications enable them to return to their normal state of mind, no longer experiencing drug-induced highs and lows.

v. MAT alleviates the person’s constant thoughts about the drug.

vi. MAT can also decrease issues related to withdrawal and cravings. These changes allow the person to think about and focus on lifestyle changes enabling them to return to a healthy life.

vii. MAT treats opioid addiction in the same way certain medications are taken to treat heart disease or other illnesses.

viii. It is safe for people to use MAT specific medications for long periods of time, such as months, years, or even over a lifetime.

ix. When used appropriately, the use of medication in treating SUDs will not result in a new addiction. MAT is intended to aid people in managing their addiction, enabling them to maintain the benefits experienced through recovery (SAMHSA, 2016b).

b. Medications used: i. Methadone: Prevents withdrawal by making the person feel like they are still using

the drug, minus the highs and lows. Instead, the person feels normal and does not experience any discomfort. This medication is a narcotic pain reliever. Methadone is available in liquid, wafer and pill form.

ii. Buprenorphine: Similar to methadone, buprenorphine eases cravings for and withdrawal from the drug. It comes in the form of a pill or sublingual film that is placed under the tongue.

iii. Subutex®, Suboxone® (includes naloxone): Suboxone® contains a combination of buprenorphine and naloxone. Naloxone blocks the effects of opioid medication, including pain relief or feelings of well-being that can lead to opioid dependence (Indivior Inc., 2015).

iv. Naltrexone, Vivitrol® (injectable), Revia® (oral): Naltrexone works differently than methadone and buprenorphine in that it blocks the rewards that usually result from taking the drugs and getting high, such as the euphoric and sedative effects. Naltrexone comes in pill form, such as Revia® and Depade®, and in an injectable form, trade name Vivitrol®. A healthcare provider must administer the injectable


form (SAMHSA; U.S. Department of Health and Human Services, 2008).

c. Treatment facilities/availability: i. Access to appropriate treatment is an important concern for those with SUD.

ii. Pennsylvania Client Placement Criteria (PCPC) outlines principles of treatment, levels

of care and placement criteria. The PCPC is available from: http://www.ddap.pa.gov/Manuals/PA%20Client%20Placement%20Criteria%20(PCPC)%20Edition%203%20Manual.pdf

iii. Barriers to obtaining treatment include: 1. Limited capacity of treatment facilities;

2. Lack of transportation;

3. Lack of child care;

4. Work concerns;

a. The American Disabilities Act (ADA) protects a person in MAT from discrimination by the government for its benefits programs, including resources such as welfare and child care assistance and other forms of financial assistance. Furthermore, when MAT involves take-home medication, it enables patients to engage in employment, education, child care, or other important aspects of life that enhance the individual’s rehabilitation process.

b. Patients involved in MAT face unique employment challenges, especially as employers increasingly impose pre-employment drug testing and patients must wrestle with whether or not to disclose their status. Vocational training provided throughout the MAT process should include basic education about drug testing, including the fact that methadone may be detected.

5. Financial concerns/insurance issues; and a. The cost of different medications used in MAT varies, and this may need to be

taken into account when considering treatment options.

b. The Affordable Care Act now requires most insurers to cover addiction treatment benefits. In addition, the Mental Health Parity and Addiction Equity Act (MHPAEA) of 2008 requires health insurers and group health plans to provide the same level of benefits for behavioral health services that they do for primary care.

c. Not all insurance plans cover every available addiction treatment medication, and some plans cap the number of dosages and prescription refills covered for a MAT patient (SAMHSA; SAMHSA).

6. Lack of connections from intercept points to treatment facilities; a. “Warm hand-off” is an approach which involves individuals being referred to

SUD treatment when they contact an intercept point in the community such as a hospital ED, law enforcement officer, SUD treatment provider, correctional facility, or primary care provider.

http://www.ddap.pa.gov/Manuals/PA%20Client%20Placement%20Criteria%20(PCPC)%20Edition%203%20Manual.pdf

http://www.ddap.pa.gov/Manuals/PA%20Client%20Placement%20Criteria%20(PCPC)%20Edition%203%20Manual.pdf


b. Emergency departments can facilitate connections to treatment after

overdose patients are treated in the emergency room. Many projects include the use of Certified Recovery Specialists (CRS) who stay with an overdose patient until he or she can be taken directly to a treatment facility.

c. In the case of law enforcement, this involves the coordination of substance use treatment without penalizing the individual for their substance use/addiction (see “Frameworks for Law Enforcement Warm Hand-offs” below for more detail).

d. There are several ways in which law enforcement entities can facilitate the referral to treatment process for individuals who struggle with substance use: i. Assist with navigating prevention/treatment system.

ii. Link to the treatment provider/recovery community.

iii. Individualized screening, assessment, and referral to an appropriate

level of care which includes appropriate length of stay (Morrison, 2016).

d. Physicians available to treat/prescribe: i. Office Based Opioid Treatment (OBOT) is the treatment of opiate addiction with a

medication in a physicians' office and outside of the clinic system. Two medications are available: methadone and buprenorphine. Each medication has specific requirements and regulations before it can be dispensed.

ii. Treatment should be combined with psychosocial counseling to be most effective.

iii. Some unscrupulous providers are known as “pill-mills” (NAMA, 2016).

e. MAT and diversion from criminal justice system: i. Refer to treatment: Many individuals entering the criminal justice system are using

illegal drugs at the time of their arrest and/or have substance use problems. Further, many commit property crimes to obtain money to buy drugs, and participation in drug-dealing organizations often places individuals in situations where other crimes are likely to occur. For this reason, it is important that law enforcement entities play an instrumental role in facilitating and connecting individuals to the appropriate treatment that they need.

ii. Drug courts/alternate sentencing: An “alternative to incarceration” is any kind of punishment other than time in prison or jail that can be given to a person who commits a crime. Punishments other than prison or jail time place serious demands on offenders and provide them with intensive court and community supervision. Alternatives to incarceration can repair harms suffered by victims, provide benefits to the community, save money, and rehabilitate offenders (FAMM; SAMHSA, 2016a).

iii. MAT for justice-involved individuals (correctional facilities, jails, prisons, community corrections): 1. Prior to re-entry: Medication-assisted treatment (MAT) is currently underutilized

in the treatment of drug-dependent, criminal justice populations. MAT use is


largely limited to detoxification and maintenance of pregnant women in criminal justice settings.

2. During re-entry/probation/parole: MAT use prior to the community reentry period is minimal, but the period immediately following release from incarceration has a higher risk of overdose.

3. Pennsylvania has an MAT Pilot project underway to connect individuals to treatment upon release from a correctional facility (Belenko, Hiller, & Hamilton, 2014; Friedmann et al., 2012; Miller, 2013; SAMHSA, 2016a).

f. MAT during pregnancy

i. Detox: Methadone is a pure opioid-agonist with a long half-life (24 hours) which allows for daily dosing. Methadone is the medication of choice for treatment during pregnancy, because there are more data regarding neonatal outcomes following in utero exposure. It is a pregnancy category C drug and is not specifically approved for treatment of opioid dependence during pregnancy by the FDA, despite widespread recommendations as the medication of choice in pregnancy. Initiating or switching treatment to methadone should be offered to all opiate dependent pregnant patients. Methadone for the treatment of opioid dependence is available only through opioid treatment programs (OTPs).

ii. Induction: Guidelines for introducing pregnant patients to methadone have been well-established. Providers must ensure the patient is not concurrently using other drugs that could increase the risk of over-sedation. Care should also be taken to avoid increasing the dose too quickly or slowly to minimize overdosing and to forestall potential premature termination from treatment due to the inability of the medication to alleviate withdrawal, respectively. The quality of the therapeutic alliance with the health care providers initially established during assessment can help with retention.

iii. Maintenance: Opioid addiction is a chronic, relapsing disease. Acute opioid

withdrawal is physiologically stressful, characterized by profound activation of the sympathetic nervous system with hypertension, tachycardia, and gastrointestinal symptoms. In the 1970s, a series of case reports and animal studies reported stillbirth and meconium aspiration when patients presented late in gestation in acute opioid withdrawal. Coincident with these reports, randomized trials in the general opioid dependent population demonstrated that methadone maintenance decreased opioid craving and allowed rehabilitation more effectively than acute withdrawal. As methadone maintenance for the treatment of opioid dependence became accepted as appropriate medical therapy, the use of methadone during pregnancy to prevent maternal (and fetal) withdrawal was examined. Methadone maintenance during pregnancy improved prenatal care, reduced illicit drug use, and minimized the risk of fetal in utero withdrawal. These demonstrated benefits led to the current recommendation for opioid agonist maintenance for opioid dependent women during pregnancy (DDAP, 2016; Dowell, Haegerich, & Chou, 2016; VCHIP).

5. Frameworks for Law Enforcement “Warm Hand-offs” (30 minutes)

a. Two prevailing models:


i. Gloucester, Massachusetts ANGEL Initiative; Police Assisted Addiction Recovery Initiative (PAARI); and

ii. Arlington, Massachusetts Outreach Initiative.

b. Gloucester ANGEL Initiative: i. People who use drugs can report to police stations and ask for assistance in accessing

drug treatment programs.

ii. Individuals are required to surrender any drugs and drug paraphernalia (e.g. needles, spoons, etc.) and will not be charged with any crimes.

iii. An “angel” (program volunteer) will be contacted. These volunteers are called on to help an individual through the intake process. They provide support to the person as they go through the process of finding a treatment center.

iv. Once treatment is arranged, transportation will be arranged for the individual.

v. Additionally, the ANGEL Initiative partnered with local pharmacies to ensure access to nasal naloxone. 1. If an individual is unable to pay due to lack of insurance, the Gloucester P.D. will

cover the cost of the naloxone using money seized from drug dealers during investigations.

vi. Most people are eligible for the program, but there are exceptions: 1. Individuals with outstanding warrants;

2. Individuals with more than THREE drug related arrests on their criminal record

if at least one of those arrests resulted in conviction for possession with the intent to distribute OR trafficking OR drug violation within a school zone;

3. If the individual may cause harm to the volunteer ANGEL;

4. Minors under the age of 18 without the consent of parent of guardian; and

5. Individuals who may be in active withdrawal or with some other medical emergency. In this case, the individual will be transported to a hospital.

c. Arlington Outreach Initiative: This program provides direct outreach to individuals who

are struggling with heroin or opiate use problems, as well as their family members, friends, and caregivers. i. Incorporates two major components:

1. “Arlington Opiate Outreach Initiative” involves proactive outreach by police officers and a public health clinician, to help individuals who are struggling to develop a plan for recovery. The identity of these individuals is obtained via 911 calls for overdose, information gained via drug investigations (i.e. when dealers are arrested, P.D. are often left with a list of their “clients”), and community policing efforts.

2. Arlington Community Training and Support (“ACTS”) involves community-based meetings that are facilitated by the PD clinician and community substance use


intervention expert. The goal is to provide support to those struggling with addiction and their families. Includes the distribution of naloxone.

ii. Arlington Opiate Outreach Initiative (AOOI). 1. Overdose case referral:

a. Report must be filed following a response to the scene of a fatal or non-fatal overdose.

b. In non-fatal overdoses, the AOOI coordinator will begin to liaise the victim and their family members and friends or caregivers.

2. Criminal investigation information referral: a. Following the arrest of a drug dealer, the list of clients will be turned over to

the AOOI coordinator, who will then schedule a resource meeting with the user and his/her family members.

b. IF the user DOES NOT participate in the resource meeting, the case will be referred back to law enforcement officials, who will review the case and make recommendations, if applicable, for the user’s role in the drug distribution operation or unlawfully possessing drugs.

c. This process is only used as a “last resort”.

3. Field police officer referral: a. Police officers are now permitted to refer drug users to the AOOI coordinator

who will facilitate outreach.

iii. Arlington ACTS Program. 1. Provide training and support on a community level for drug uses and their

families.

2. Services include: a. Access to outpatient treatment, inpatient treatment, and medical

detoxification programs;

b. Resources for family support;

c. Access to mental health professionals;

d. Presence of certified substance use interventionist;

e. On-site OEND; and

f. Access to Veteran’s service personnel.

d. Recommendations for law enforcement: i. Establish goals and objectives for the program;

ii. Utilize resources provided by the Police Assisted Addiction Recovery Initiative; and


iii. Consider the demographics of your community and which program might be best suited to serve the target population you wish to reach.

e. Special considerations: i. Gloucester ANGEL program:

1. In the case of a participant who does not have insurance, it may be necessary to partner with treatment centers that offer scholarship programs.

2. Collaboration with transportation and/or ambulance services will be necessary in order to ensure that individuals can get to the recommended treatment service.

3. For treatment that is not local, ensure a mechanism is in place to assist participants with air fare or bus fare, especially if these participants do not have the finances to afford plane and/or bus tickets (e.g. scholarship programs).

4. For individuals who cannot access treatment immediately (i.e. beds are not available for a period of time OR beds are not available at all), have a mechanism in place to ensure that individuals are safe. a. For example, if a bed is not available at a treatment center for a couple of days,

it may be necessary to partner with a hospital who can admit that individual until the bed becomes available.

f. List of available resources provided by PAARI (http://paariusa.org/): i. List of documents are available here: http://paariusa.org/documents/

1. These documents include templates for: a. Partnering with organizations;

b. Volunteer forms, including confidentiality agreement;

c. Participant intake forms; and

d. Participant agreement forms.

g. Program model website:

i. Arlington Outreach Initiative Program Policy: http://paariusa.org/wp-content/uploads/sites/46/2015/09/20150723101427154.pdf

ii. Gloucester ANGEL Program Policy: http://paariusa.org/wp-content/uploads/sites/46/2015/09/Angel-program-policy-Aug-7-2015.pdf

6. Prescription Drug Monitoring Programs a. What are Prescription Drug Monitoring Programs (PDMPs)?

i. PDMPs collect data from pharmacies, outpatient hospital pharmacies, outpatient clinics, and others about dispensed and controlled substances (Compton, Boyle, & Wargo, 2015). These statewide databases are accessible to clinicians, pharmacists, and in some states, law enforcement, and can be used to track prescribing practices, thus reducing overprescribing and “doctor shopping” (Compton et al., 2015).

ii. PDMPs vary from state to state regarding what entity monitors the PDMP and who is

http://paariusa.org/

http://paariusa.org/documents/

http://paariusa.org/wp-content/uploads/sites/46/2015/09/20150723101427154.pdf

http://paariusa.org/wp-content/uploads/sites/46/2015/09/20150723101427154.pdf

http://paariusa.org/wp-content/uploads/sites/46/2015/09/Angel-program-policy-Aug-7-2015.pdf

http://paariusa.org/wp-content/uploads/sites/46/2015/09/Angel-program-policy-Aug-7-2015.pdf


required to use the program.

iii. Reactive vs. Proactive (American Medical Association, 2011): 1. Reactive PDMPs “generate solicited reports only in response to a specific inquiry

made by a prescriber, dispenser, or other party with appropriate authority”.

2. Proactive PDMPs provide requested reports and “identify and investigate cases, generating unsolicited reports whenever suspicious behavior is detected”.

b. Components of a strong PDMP (National Alliance for Model State Drug Laws, 2015b)

i. Drugs monitored: 1. Should include Schedule II through Schedule V drugs in the federal controlled

substances act;

2. Scheduled drugs under the state controlled substances act; and

3. Any other drugs that may be of concern for specific states.

ii. Advisory committee: 1. The committee should be established to provide input and advice about the

establishment and maintenance of the PDMP.

2. The committee should pay attention to improving patient care and developing criteria for dependence and misuse and prescriber overprescribing.

3. The committee should also provide input and advice about technological improvements geared toward improving the system for reporting and accessing the prescription information. Improvements should be made to improve communication with other states’ PDMPs.

4. The committee can be made up of as many members that the state feels is necessary to best meet the needs of the state.

iii. Reporting of prescription monitoring information: 1. Dispensers report the standard patient, prescriber, and drug information.

2. Users report information about the identity of the person picking up the

prescription, especially if the person is picking up the prescription for another individual.

3. Users report the payment method to better detect potential fraud or diversion.

4. It is suggested that reporting occur within 24 hours of dispensing (this varies by state).

iv. Unsolicited and proactive disclosure: 1. PDMP should proactively provide data to prescribers, dispensers, law

enforcement, etc.

2. The information should be provided to the patient’s prescribers and/or


dispensers before law enforcementestablish referral to treatment first, rather than to law enforcement, especially if there is no evidence of illegal activity.

v. Disclosure of de-identified information: 1. Statute should allow the administrator of the PDMP to disclose de-identified

information for statistical, public policy, public research, or educational purposes.

vi. Authorized recipients: 1. Authorized recipients of PDMP information should include prescribers,

dispensers, law enforcement and other criminal justice personnel (e.g. prosecutors), prescriber and dispenser professional licensing boards or agencies, and patients.

2. States should also consider authorized users to be individuals who could use the data to improve patient care and safety. These individuals can include: medical examiners, county coroners, representatives of SUD treatment programs, representative from Medicaid or other health insurance plans.

vii. Designees: 1. Statute should allow prescribers and dispensers to designate someone to act as

an agent for the purposes of submitting or obtaining data from the PDMP.

2. Ideally, designees should be licensed or registered health care professionals, such as physician assistants, registered nurses, or pharmacy technicians.

3. Designees should be directly supervised by the prescriber or dispenser, and the prescriber or dispenser should be liable for inappropriate behavior.

4. The number of designees allowed would be determined by the state.

viii. Education, training, or instruction for authorized users: 1. Authorized users of the PDMP should demonstrate that they have the education

or training necessary to responsibly and properly use the information.

2. It should be a requirement that authorized users provide evidence of this education and training.

3. Education and training should be provided to health professionals regarding prescribing practices, pharmacology and identification, treatment and referral of patients addicted to or dependent on substances that are monitored by the PDMP.

ix. Standards and procedures for access to and use of PDMP: 1. Establish standards and regarding access to and use of the PDMP; and

2. Health licensing agencies or boards should lead the process of establishing these

standards and procedures.

x. Registration with the PDMP: 1. All prescribers with a DEA number or state controlled substance registration

number should be required to register with the PDMP.


xi. Requirement to query the PDMP:

1. PDMP statute should require prescribers (or designee) to query the PDMP prior to initially prescribing a medication or personally dispensing a controlled substance to the patient.

2. Query should be done if the patient’s treatment extends beyond 90 days. Requests should be made periodically throughout this period.

xii. Linkage to addiction treatment professionals: 1. State officials should establish appropriate linkage to addiction treatment

professionals for patients who may have a substance use problem.

xiii. Interstate sharing of PDMP data: 1. Each state with a PDMP should participate in interstate sharing of data.

2. Recipients of PDMP data from other states may include prescribers, dispensers,

law enforcement representatives, and/or PDMP officials.

xiv. Confidentiality protections: 1. Confidentiality protections are important. PDMP data should NOT be subject to

open or public records laws. PDMP should NOT be subject to civil subpoena or disclosed, discoverable, or compelled to be produced in any civil proceedings. PDMP data should NOT be deemed admissible as evidence in civil proceedings where a prescriber or dispenser is not a named party.

2. PDMP administering agency should maintain procedures to protect the privacy or confidentiality of patients.

xv. Evaluation component: 1. Evaluation is crucial to determining the cost benefits of PDMPs, impacts of the use

of the PDMP data, recommended operational updates and improvements, and other information that may be relevant to policy, research, and education involving the use of controlled substances and drugs that are monitored by the PDMP.

c. Pennsylvania PDMP (ABC-MAP):

i. Prior to the new law passed in 2014 (Act 191), PA only required the reporting of Schedule II drugs (i.e. Vicodin®, methadone, OxyContin®, and fentanyl).

ii. Act 191 requires the reporting of Schedule II through Schedule V drugs (Table 1). Additionally, dispensers (including mail order and internet pharmacies) are now required to collect and input information into the PDMP within 72 hours (3 days) of dispensing a controlled substance.

iii. Prescribers are now required to query the system the first time a patient is prescribed a controlled substance and/or if the prescriber has reason to believe that a patient maybe abusing or diverting medications.

iv. Prescribers are not required to consult the PDMP for repeat prescriptions of an


existing patient.

v. Prescribers are encouraged to use the information from the PDMP to improve the treatment and care of their patients. If prescribers suspect that their patient may have an SUD, they should begin the referral process to appropriate SUD treatment programs.

vi. Pennsylvania is able to share data with other states that have PDMP and authorized users in other states (National Alliance for Model State Drug Laws, 2015a). Ohio, West Virginia, New York, and New Jersey share data with other PDMPs and authorized users in other states. Maryland and Delaware share information with other PDMPs.

vii. Exceptions to ABC-MAP reporting requirements (Pennsylvania Medical Society): 1. Licensed health care facilities that dispense medication for the purpose of

administration in the licensed health care facility;

2. Correctional facility or its contractors if the person cannot lawfully visit a prescriber outside of the facility without being escorted by a corrections officer;

3. An authorized person who administers a controlled substance, device, or other drug;

4. Licensed provider in the Living Independence for the Elderly (LIFE) program, which is a managed care program that provides medical and supportive services to eligible elderly individuals, so they can continue to live independently;

5. Provider of hospice as defined in the Health Care Facilities Act (P.L. 130, No. 48);

6. Prescriber at a licensed health facility if the quantity of controlled substances dispensed is limited to an amount adequate to treat the patient for a maximum of five days and does not allow for a refill;

7. Veterinarians.

Table 1: Drug Enforcement Agency (DEA) Drug Schedules

Schedule Classification

Description Examples of Drugs

Schedule I Drugs that have no current accepted medical

use and have a high potential for SUDs and for severe physical and psychological dependence.

Heroin, marijuana, peyote, LSD, Ecstasy

Schedule II Drugs with high potential for dependence,

leading to potentially severe psychological and physical dependence.

Products containing >15 milligrams per dosage unit

of hydrocodone (Vicodin®), cocaine, methamphetamine,

methadone, oxycodone (OxyContin®), Adderall®,

Ritalin® Schedule III Drugs with moderate to low potential for Products containing less


Schedule Classification

Description Examples of Drugs

physical and psychological dependence. Potential for dependence is less than Schedule I

or II but more than schedule IV or V.

than 90 milligrams of codeine per dosage unit

(Tylenol with Codeine®), ketamine, anabolic steroids,

buprenorphine (Suboxone®)

Schedule IV Drugs with low potential for dependence and a

low risk of physical and psychological dependence

Xanax®, Klonopin®, Valium®, Ativan®

Schedule V

Drugs with lower potential for dependence than Schedule IV drugs. These drugs consist

primarily of preparations consisting of limited quantities of certain narcotics.

Cough preparations containing no more than 200

milligrams of codeine per 100 milliliters (Robitussin

AC®, Phenegran with Codeine®)

Adapted from http://www.dea.gov/druginfo/ds.shtml

7. Prescribing Practices a. Centers for Disease Control and Prevention (CDC) guidelines for opioid prescribing:

i. CDC released new guidelines for opioid prescribing in March, 2016 in response to the epidemic of opioid use disorders and overdose. The new recommendations are to be used for chronic pain opioid prescribing outside of active cancer, palliative, and end-of-life care.

ii. CDC recommends the following practices when considering and prescribing opioid therapy for chronic, non-cancer pain (Dowell et al., 2016): 1. Determining when to initiate or continue opioid for chronic pain:

a. Non-pharmacologic therapy and non-opioid pharmacological therapy is recommended for chronic pain. If opioids are prescribed, non-pharmacologic therapy and non-opioid pharmacologic therapy should be combined, when appropriate.

b. Before opioids are prescribed for chronic pain, physicians and patients should establish and agree on treatment goals. These should include realistic goals for pain and function and how discontinuation would occur if the risks outweigh the benefits of the opioid therapy.

c. Before starting opioid therapy, clinicians should discuss the risks and realistic benefits of opioid therapy. These discussions should also happen for patients who have previously begun opioid therapy.

2. Opioid selection, dosage, duration, follow-up, and discontinuation: a. Clinicians should prescribe immediate-release opioid medications instead of

extended release/long-acting formulations.

b. When opioid therapy is started, the clinician should prescribe the lowest effective dose. Clinicians should weigh the benefits and risk when increasing the dosage of opioid medications for their patients.

http://www.dea.gov/druginfo/ds.shtml


c. When opioids are being prescribed for acute pain, clinicians should prescribe

the lowest effective dose of immediate-release opioid medications. Clinicians should not prescribe more than what is needed to treat severe and acute pain. CDC recommends a supply for 3 days or less; rarely should a 7-day supply be needed for acute pain.

d. Patients should be evaluated within 1 to 4 weeks after starting opioid therapy for chronic pain or increasing the dose. Clinicians should evaluate benefits and risks with patients at least every 3 months.

3. Assessing risk and addressing harms of opioid use: a. Before starting and during the continuation of opioid therapy, clinicians

should evaluate patient risk-factors for harm associated with opioid therapy. Clinicians should consider introducing risk mitigation strategies for patients on chronic opioid therapy, including co-prescribing of naloxone.

b. Clinicians should utilize PDMPs to assess the patients’ history/risk of SUDs. The PDMP can also be used to determine additional prescriptions that the patient may be receiving. PDMP should be reviewed before starting opioid therapy, periodically throughout opioid therapy, and before prescribing additional medication.

c. Urine drug testing should be used before starting opioid therapy for chronic pain. It is also recommended that urine drug testing be conducted during opioid therapy to test for additional prescribed medications and illicit drugs.

d. Avoid the co-prescription of opioids and benzodiazepines whenever possible.

e. Clinicians should offer and arrange for evidence-based treatment (usually MAT combined with behavioral therapies) for patients who may have an opioid use disorder.

b. Report from the American Dental Association (ADA) regarding opioid prescribing (American Dental Association (n.d.)): i. Encourages continuing education regarding the appropriate use of opioids in order

to promote responsible prescribing practices and limit the instances of diversion.

ii. Dentists who prescribe opioids for dental pain are encouraged to be mindful of the potential for dependency.

iii. Dentists who prescribe opioids are encouraged to periodically review their

compliance with the DEA recommendations and regulations.

iv. Dentists are encouraged to recognize their responsibility to have opioids medications available to those who need them, for preventing these medications from becoming a source of harm or dependence, and for understanding the special issues surrounding pain management for individuals who are already opioid dependent.

v. Dentists who practice good judgment and prescribe opioids in good faith should not


be held responsible for the willful and deceptive behavior of individuals who obtain opioids for non-dental pain treatment purposes.

vi. Dental schools should provide education about addiction medicine and pain

management as part of the core curriculum.

c. Pennsylvania Medical Society guidelines for opioid prescribing: i. Pennsylvania has guidelines for the use of opioid therapy in various specialty areas.

ii. Treatment of chronic pain (Pennsylvania Medical Society, 2014b):

1. Before initiating opioid therapy, clinicians should document a history of the patient. This history should include documentation and verification of current medications. Clinicians should also include documentation about psychiatric conditions and any prior SUDs. a. Opioids should rarely be used as a stand-alone therapy for chronic pain.

Opioids should be consider as part of a multi-modal treatment for chronic pain.

2. When opioid therapy is started for chronic pain, clinicians should discuss the risks and benefits with the patients. Reasonable goals should be discussed with the patient and agreed upon.

3. Initial treatment with opioids should be done as a therapeutic trial, in order for the physician to assess whether or not opioid therapy is appropriate.

4. Opioid dosages should be individualized to the patient’s health status, previous exposure to opioids, response to treatment, and predicted or observed adverse events. a. Special consideration and cautions should be exercised when prescribing

opioids to: women who are pregnant or breastfeeding; patients who are also prescribed benzodiazepines; patients with co-occurring psychiatric disorders; elderly patients; and patients being prescribed methadone.

b. Physicians should counsel patients when the opioid dose is increased.

5. Physicians should be very cautious when prescribing dosages above 100 mg/day of oral morphine or its equivalent, as there is an increased risk of harm. Specialty care consultation may be appropriate for patients who are receiving high doses of opioids.

6. Patients who are on opioid therapy should be reassessed by their physician on a routine basis. Monitoring should include documentation of responses to therapy, presence of adverse events, and adherence to the prescribed therapy.

7. Conduct careful monitoring of aberrant drug-related behaviors. Monitoring should include periodic checks of the PDMP for additional opioid prescriptions and urine samples to test for other drugs and controlled substances.

8. In patients who are at risk for SUDs, clinicians should increase the frequency of assessments and may consider referral to psychiatric or psychological care


and/or addiction treatment.

9. If patients engage in aberrant drug-related behaviors, clinicians should determine if the risks outweigh the benefits and may wish to restructure or discontinue the therapy. Referral for addiction treatment should be considered and provided.

10. Opioid therapy should be discontinued for patients who engage in repeated aberrant drug-related behavior or drug-dependence diversion.

11. Clinicians should be aware of and understand the current federal and state laws and regulations that govern the use of opioid therapy for chronic non-cancer pain.

iii. Emergency department (ED) guidelines (Pennsylvania Medical Society, 2014a): 1. Prescriptions for opioids should be limited to the amount needed until the next

follow-up and generally should not exceed seven days.

2. Non-opioid medications should be considered for the treatment of pain.

3. When opioids are indicated, the lowest potency opioid should be prescribed.

4. An ED provider should dispense only the amount needed to control the patient’s pain until the patient can access a pharmacy.

5. Long-acting opioids (i.e. OxyContin®), extended-release morphine, or methadone should not be prescribed unless coordinated with the outpatient provider.

6. The patient should not receive opioids for chronic or recurrent pain from multiple providers.

7. ED providers should access the PDMP as indicated.

8. ED providers should not replace lost or stolen prescriptions for controlled substances.

9. ED providers should not refill prescriptions for pain medications; refills should be coordinated with the primary or specialty care provider.

10. If an ED provider is concerned about possible addiction, they should encourage the patient to seek detoxification services.

d. Co-prescribing of naloxone with opioid prescription:

i. Physicians are encouraged to explore co-prescribing naloxone to patients who are on high doses of opioids for the treatment of chronic pain (Bailey & Wermeling, 2014).

ii. Pharmacists and pharmacy staff should be trained in overdose prevention, including when and how naloxone should be administered (Bailey & Wermeling, 2014). Trained pharmacists and pharmacy staff can then train individuals who are receiving naloxone via prescription.


iii. Project Lazarus in Wilkes County, North Carolina reported on circumstances in which an individual may warrant a prescription for naloxone (Project Lazarus, 2007): 1. Any individual who receives emergency medical care for an opioid overdose;

2. A person suspected of illicit or non-medical use of opioids;

3. Any person prescribed a high-dose opioid (> 100 mg/day morphine or

equivalent);

4. Any person who is new to taking opioids and is receiving a methadone prescription;

5. Any person receiving an opioid prescription with a history of smoking, COPD, emphysema ,or other respiratory illness;

6. Any person receiving an opioid prescription with a history of renal or hepatic function disease;

7. Any person receiving an opioid prescription with a history of known alcohol use;

8. Any person receiving an opioid prescription with concurrent benzodiazepine use;

9. Any person receiving an opioid prescription with concurrent SSRI or TCA anti-depressant use;

10. Individuals who are being released from incarceration;

11. Any person released from an opioid detoxification or treatment program

12. Individuals who request a naloxone prescription; and

13. Individuals who are entering a methadone program, whether for opioid use disorder or pain management.

e. Drug collection initiatives (supply-reduction):

i. Useful in preventing diversion and non-medical use of prescription drugs.

ii. Drug collection boxes 1. Permanent boxes that can accommodate the disposal of unused/unwanted

prescription drugs. For example, Tennessee implemented this strategy by placing drug collection boxes at local law enforcement agencies (Gray, Hagemeier, Brooks, & Alamian, 2015). Drug collection boxes are unique because they are consistently available to individuals.

iii. Drug take-back events provide a safe and convenient way of disposing of unused/unwanted medications. The Drug Enforcement Agency (DEA) is one agency that sponsors drug take-back days.

iv. Collection boxes are available to law enforcement agencies from the PA Chief of Police Association.


E. Implementation

(30 minutes) Objectives: Apply strategic plan for your county to implementation of intervention strategies; Identify timeline for implementation; Describe significance of fidelity as applied to the strategic plan; and Identify adaptation(s) from the strategic plan.

E.1 Implementation of Strategic Plan

1. Review– characteristics, data on overdoses, readiness level, coalition composition and health, impact model, and evidence-based intervention strategies.

2. Identify the current situation of intervention efforts.

3. Implement your strategic plan.

4. Monitor implementation progress and consider: a. Fidelity: How well does your program implementation reflect your plan/impact model?

b. Adaptation: What changes did you make in implementing the program?

F. Evaluation

(15 minutes) Objectives: Discuss benefits of an evaluation plan for your program; Differentiate between short-term and long-term evaluations; List potential evaluation methods; and Identify possible evaluation resources.

F.1 Evaluation of Strategic Plan

1. An evaluation plan is an important component of your strategic plan and should be completed early in the process.

2. The evaluation plan should include input from key stakeholders including: a. Identifying program goals and expected change in the community;

b. Generating milestones and metrics based on the strategic plan;

c. Measuring inclusion of community sectors and subpopulations.

3. Document the baseline conditions prior to program implementation so you can gauge

your progress in meeting your goals. a. Compare actual outcomes against expected outcomes on both a short-term and long-term

basis. Community initiatives are complex and may be difficult to measure.

b. Change may not be immediately observable.

4. Evaluation methods may include progress reports, activity logs, surveys, or measures of change in the community (e.g. death rates).


5. Document and report results.

6. Some funders will require an external evaluator or specific metrics.

7. Staff from the TAC will provide assistance as you develop your evaluation plan.

G. Sustainability

(15 minutes) Objectives: List possible sources of funding to sustain your coalition; Identify potential resources your coalition can access; Outline key components of a typical grant application; and Describe your organization and how it can address overdose in your county.

G.1 Sustaining Coalition and Relationships

1. A sustainability plan addresses how you can maintain your coalition and the

relationships, resources and connections you develop for long-term effectiveness.

2. Sustainability planning is a process, not a one-time event.

3. Identify which elements of the project should be maintained, adapted, or eliminated over time.

4. List and prioritize resources needed to achieve goals.

5. Identify methods to obtain necessary resources.

6. Plan for potential obstacles: a. Identify possible barriers;

b. Plan strategies to overcome.

7. Grant funds are a potential source of funding for community-based overdose

prevention coalitions. a. Understand funders’ specific rules regarding eligibility;

b. Pay attention to submission deadlines;

c. Include all required components of the application;

d. Describe your organization and project:

i. Why unique;

ii. Why necessary;

iii. Where, why and how you plan to address the problem.


8. Common sections of a grant application: a. Narrative; b. Goals and objectives; c. Methods; d. Evaluation Plan.

9. TAC staff can provide technical assistance with grant writing and development.


References:

American Dental Association (n.d.). Statement on the use of opioids in the treatment of dental pain. Retrieved from http://www.ada.org/en/about-the-ada/ada-positions-policies-and-statements/statement-on-opioids-dental-pain

American Medical Association. (2011). Prescription Drug Monitoring Programs. Baca, C. T., & Grant, K. J. (2005). Take‐home naloxone to reduce heroin death. Addiction, 100(12),

1823-1831. Bailey, A. M., & Wermeling, D. P. (2014). Naloxone for Opioid Overdose Prevention Pharmacists’

Role in Community-Based Practice Settings. Annals of Pharmacotherapy, 1060028014523730.

Banta-Green, C. J., Beletsky, L., Schoeppe, J. A., Coffin, P. O., & Kuszler, P. C. (2013). Police Officers' and Paramedics' Experiences with Overdose and Their Knowledge and Opinions of Washington State's Drug Overdose-Naloxone-Good Samaritan Law. J Urban Health. doi:10.1007/s11524-013-9814-y

Barocas, J. A., Baker, L., Hull, S. J., Stokes, S., & Westergaard, R. P. (2015). High uptake of naloxone-based overdose prevention training among previously incarcerated syringe-exchange program participants. Drug Alcohol Depend, 154, 283-286.

Belenko, S., Hiller, M., & Hamilton, L. (2014). Treating Substance Use Disorders in the Criminal Justice System. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3859122/

Bennett, A. S., Bell, A., Tomedi, L., Hulsey, E. G., & Kral, A. H. (2011). Characteristics of an overdose prevention, response, and naloxone distribution program in Pittsburgh and Allegheny County, Pennsylvania. Journal of Urban Health, 88(6), 1020-1030.

Calcaterra, S., Glanz, J., & Binswanger, I. A. (2013). National trends in pharmaceutical opioid related overdose deaths compared to other substance related overdose deaths: 1999-2009. Drug Alcohol Depend, 131(3), 263-270. doi:10.1016/j.drugalcdep.2012.11.018

Community Catalyst, I. (2003). Strength in numbers: A guide to building community coalitions. Compton, W. M., Boyle, M., & Wargo, E. (2015). Prescription opioid abuse: problems and responses.

Prev Med, 80, 5-9. DDAP. (2016). DDAP Treatment Manual. Retrieved from

http://www.ddap.pa.gov/Manuals/Treatment%20Manual.pdf Doe-Simkins, M., Walley, A. Y., Epstein, A., & Moyer, P. (2009). Saved by the nose: bystander-

administered intranasal naloxone hydrochloride for opioid overdose. Am J Public Health, 99(5), 788-791. doi:10.2105/AJPH.2008.146647

Dowell, D., Haegerich, T. M., & Chou, R. (2016). CDC guideline for prescribing opioids for chronic pain—United States, 2016. JAMA, 315(15), 1624-1645.

Drug Enforcement Agency (n.d.). Drug Fact Sheet: Heroin. Retrieved from http://www.dea.gov/druginfo/drug_data_sheets/Heroin.pdf

FAMM. Alternatives to Incarceration Iin a Nutshell. Retrieved from http://famm.org/wp-content/uploads/2013/08/FS-Alternatives-in-a-Nutshell-7.8.pdf

Friedmann, P. D., Hoskinson Jr, R., Gordon, M., Schwartz, R., Kinlock, T., Knight, K., . . . Sacks, S. (2012). Medication-assisted treatment in criminal justice agencies affiliated with the criminal justice-drug abuse treatment studies (CJ-DATS): availability, barriers, and intentions. Substance Abuse, 33(1), 9-18.

Giglio, R., Li, G., & DiMaggio, C. (2015). Effectiveness of bystander naloxone administration and overdose education programs: a meta-analysis. Injury epidemiology, 2(10).

Gray, J., Hagemeier, N., Brooks, B., & Alamian, A. (2015). Prescription Disposal Practices: A 2-Year Ecological Study of Drug Drop Box Donations in Appalachia. Am J Public Health, 105(9), e89-e94.

http://www.ada.org/en/about-the-ada/ada-positions-policies-and-statements/statement-on-opioids-dental-pain

http://www.ada.org/en/about-the-ada/ada-positions-policies-and-statements/statement-on-opioids-dental-pain

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3859122/

http://www.ddap.pa.gov/Manuals/Treatment%20Manual.pdf

http://www.dea.gov/druginfo/drug_data_sheets/Heroin.pdf

http://famm.org/wp-content/uploads/2013/08/FS-Alternatives-in-a-Nutshell-7.8.pdf

http://famm.org/wp-content/uploads/2013/08/FS-Alternatives-in-a-Nutshell-7.8.pdf


Hawk, K. F., Vaca, F. E., & D'Onofrio, G. (2015). Reducing Fatal Opioid Overdose: Prevention, Treatment and Harm Reduction Strategies. Yale J Biol Med, 88(3), 235-245.

Indivior Inc. (2015). Treatment Plan. Retrieved from http://www.suboxone.com/treatment-plan/find-a-doctor?gclid=CO7g8rLHzcwCFcUmhgodxN0K8w

Jones, C. M. (2013). Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers–United States, 2002–2004 and 2008–2010. Drug Alcohol Depend, 132(1), 95-100.

Longo, D. L., Compton, W. M., Jones, C. M., & Baldwin, G. T. (2016). Relationship between Nonmedical Prescription-Opioid Use and Heroin Use. New England Journal of Medicine, 374(2), 154-163.

Lott, D. C., & Rhodes, J. (2016). Opioid overdose and naloxone education in a substance use disorder treatment program. The American Journal on Addictions, 25(3), 221-226.

Maxwell, S., Bigg, D., Stanczykiewicz, K., & Carlberg-Racich, S,. (2006). Prescribing naloxone to actively injecting heroin users: a program to reduce heroin overdose deaths. Journal of Addictive Diseases,25(3), 89–96. Retrieved from http://www.ncbi.nlm.nih.gov/pubmed/16956873

Miller, N. (2013). RSAT Training Tool. Retrieved from http://www.rsat-tta.com/Files/Trainings/FinalMAT

Morrison, R. T., G. (2016). NASADAD. Retrieved from http://nasadad.org/wp-content/uploads/2016/01/16-January-12-Exec-Dirs-Roundtable.pdf

NAMA. (2016). Office Based Opioid Treatment (OBOT) Retrieved from http://www.methadone.org/library/obot_resources.html

National Alliance for Model State Drug Laws. (2015a). Annual Review of Prescription Monitoring Programs. Retrieved from http://www.namsdl.org/library/3449DDCF-BB94-288B-049EB9A92BAD73DF/

National Alliance for Model State Drug Laws. (2015b). Components of a Strong Prescription Monitoring Program. Retrieved from http://www.namsdl.org/library/8B509B0A-D51E-472E-B9F10054CE52F2F6/

National Institute on Drug Abuse. (2012). Fentanyl. Retrieved from https://www.drugabuse.gov/drugs-abuse/fentanyl

Organization, W. H. (2014). Community Management of Opioid Overdose. Geneva: World Health Organization. Retrieved from http://www.ncbi.nlm.nih.gov/books/NBK264311/

Paulozzi, L. J., & Xi, Y. (2008). Recent changes in drug poisoning mortality in the United States by urban-rural status and by drug type. Pharmacoepidemiol Drug Saf, 17(10), 997-1005. doi:10.1002/pds.1626

Paulozzi, L. J., & Xi, Y. (2008). Recent changes in drug poisoning mortality in the United States by urban–rural status and by drug type. Pharmacoepidemiology and drug safety, 17(10), 997-1005.

Pennsylvania Medical Society. (2014a). Pennsylvania guidelines emergency department (ED) pain treatment guideline. Retrieved from https://www.pamedsoc.org/PAMED_Downloads/PA%20ED%20Guidelines%20Opioids.pdf

Pennsylvania Medical Society. (2014b). Pennsylvania guidelines on the use of opioids to treat chronic noncancer pain. Retrieved from https://www.pamedsoc.org/PAMED_Downloads/PAGuidelinesonOpioids.pdf

Project Lazarus. (2007). Policy briefing document. Retrieved from http://intranasal.net/Peer%20Reviewed%20literature/Project%20Lazarus,%20North%20Carolina%20IN%20Naloxone%202007.pdf

Ray, B., O’Donnell, D., & Kahre, K. (2015). Police officer attitudes towards intranasal naloxone training. Drug Alcohol Depend, 146, 107-110.

http://www.suboxone.com/treatment-plan/find-a-doctor?gclid=CO7g8rLHzcwCFcUmhgodxN0K8w

http://www.suboxone.com/treatment-plan/find-a-doctor?gclid=CO7g8rLHzcwCFcUmhgodxN0K8w

http://www.ncbi.nlm.nih.gov/pubmed/16956873

http://www.rsat-tta.com/Files/Trainings/FinalMAT

http://www.rsat-tta.com/Files/Trainings/FinalMAT

http://nasadad.org/wp-content/uploads/2016/01/16-January-12-Exec-Dirs-Roundtable.pdf

http://nasadad.org/wp-content/uploads/2016/01/16-January-12-Exec-Dirs-Roundtable.pdf

http://www.methadone.org/library/obot_resources.html

http://www.namsdl.org/library/3449DDCF-BB94-288B-049EB9A92BAD73DF/

http://www.namsdl.org/library/3449DDCF-BB94-288B-049EB9A92BAD73DF/

http://www.namsdl.org/library/8B509B0A-D51E-472E-B9F10054CE52F2F6/

http://www.namsdl.org/library/8B509B0A-D51E-472E-B9F10054CE52F2F6/

https://www.drugabuse.gov/drugs-abuse/fentanyl

http://www.ncbi.nlm.nih.gov/books/NBK264311/

https://www.pamedsoc.org/PAMED_Downloads/PA%20ED%20Guidelines%20Opioids.pdf

https://www.pamedsoc.org/PAMED_Downloads/PAGuidelinesonOpioids.pdf

http://intranasal.net/Peer%20Reviewed%20literature/Project%20Lazarus,%20North%20Carolina%20IN%20Naloxone%202007.pdf

http://intranasal.net/Peer%20Reviewed%20literature/Project%20Lazarus,%20North%20Carolina%20IN%20Naloxone%202007.pdf


Rosenblum, A., Marsch, L. A., Joseph, H., & Portenoy, R. K. (2008). Opioids and the treatment of chronic pain: controversies, current status, and future directions. Exp Clin Psychopharmacol, 16(5), 405.

Rudd, R. A., Aleshire, N., Zibbell, J. E., & Gladden, R. M. (2016). Increases in drug and opioid overdose deaths-United States, 2000-2014. MMWR: Morbidity and mortality weekly report, 64(50-51), 1378-1382.

SAMHSA. Buprenorphine. Retrieved from http://buprenorphine.samhsa.gov/faq.html#A1 SAMHSA. Insurance and Payments. Retrieved from http://www.samhsa.gov/medication-assisted-

treatment/treatment/insurance-payments SAMHSA. Medications Used in MAT. Retrieved from http://www.samhsa.gov/medication-assisted-

treatment/treatment#medications-used-in-mat SAMHSA. (2016a). Emerging Issues in Behavioral Health and the Criminal Justice System.

Retrieved from http://www.samhsa.gov/criminal-juvenile-justice/behavioral-health-criminal-justice

SAMHSA. (2016b). Medication-Assisted Treatment (MAT). Retrieved from http://www.samhsa.gov/medication-assisted-treatment

Substance Abuse and Mental Health Services Administration. (2016). Opioid Overdose Prevention Toolkit. Retrieved from http://store.samhsa.gov/shin/content//SMA16-4742/SMA16-4742.pdf

The Network for Public Health Law, D. O. P. i. P. (2014). Act 139 Fact Sheet. Retrieved from https://www.networkforphl.org/_asset/9r6xcz/PA-overdose-prevention.pdf

U.S. Department of Health and Human Services. (2008). Medication-Assisted Treatment Retrieved from http://buprenorphine.samhsa.gov/tip43_curriculum.pdf

U.S. Department of Housing and Urban Development. (2009). Building effective coalitions. U.S. Department of Housing and Urban Development Office of Community Planning and Development. Retrieved from https://www.hudexchange.info/resources/documents/BuildingEffectiveCoalitions.pdf

VCHIP. Vermont Guidelines for Medication Assisted Treatment (MAT) for Pregnant Women. Retrieved from https://www.uvm.edu/medicine/vchip/documents/VCHIP_4MAT_GUIDELINES.pdf

Wagner, K. D., Liu, L., Davidson, P. J., Cuevas-Mota, J., Armenta, R. F., & Garfein, R. S. (2015). Association between non-fatal opioid overdose and encounters with healthcare and criminal justice systems: Identifying opportunities for intervention. Drug Alcohol Depend, 153, 215-220.

Wakeman, S. E., Bowman, S. E., McKenzie, M., Jeronimo, A., & Rich, J. D. (2009). Preventing death among the recently incarcerated: an argument for naloxone prescription before release. J Addict Dis, 28(2), 124-129.

http://buprenorphine.samhsa.gov/faq.html#A1

http://www.samhsa.gov/medication-assisted-treatment/treatment/insurance-payments

http://www.samhsa.gov/medication-assisted-treatment/treatment/insurance-payments

http://www.samhsa.gov/medication-assisted-treatment/treatment#medications-used-in-mat

http://www.samhsa.gov/medication-assisted-treatment/treatment#medications-used-in-mat

http://www.samhsa.gov/criminal-juvenile-justice/behavioral-health-criminal-justice

http://www.samhsa.gov/criminal-juvenile-justice/behavioral-health-criminal-justice

http://www.samhsa.gov/medication-assisted-treatment

http://store.samhsa.gov/shin/content/SMA16-4742/SMA16-4742.pdf

http://store.samhsa.gov/shin/content/SMA16-4742/SMA16-4742.pdf

https://www.networkforphl.org/_asset/9r6xcz/PA-overdose-prevention.pdf

http://buprenorphine.samhsa.gov/tip43_curriculum.pdf

https://www.hudexchange.info/resources/documents/BuildingEffectiveCoalitions.pdf

https://www.uvm.edu/medicine/vchip/documents/VCHIP_4MAT_GUIDELINES.pdf

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