Support the Prevention Agenda by Preventing Non-Medical Prescription Opioid Use and Overdose What is an opioid? Opioids are a type of pain-relief medication. According to the National Institute on Drug Abuse, opioids reduce the intensity of pain signals reaching the brain and affect those brain areas controlling emotion, which diminishes the effects of a painful stimulus. Some common medications in this category include hydrocodone (e.g., Vicodin), oxycodone (e.g., OxyContin, Percocet), morphine (e.g., Kadian, Avinza), and codeine. Opioids are synthetically produced narcotics that mimic the naturally occurring opiates found in the resin of the opium poppy. When they are misused, prescribed opioids can have similar effects as heroin, making them highly addictive. Some people take up heroin use after abusing opioids because it is less expensive and easier to obtain than these prescription drugs. 1 Why address opioid use in your county? Non-medical use of opioids such as heroin and prescription pain relievers is a serious public health problem that affects the health, social, and economic welfare of individuals and communities. It is estimated that 2.1 million people in the United States suffered from substance use disorders related to prescription opioid pain relievers in 2012 and an estimated 467,000 people were addicted to heroin. The number of unintentional overdose deaths from prescription pain relievers has soared in the United States, more than quadrupling since 1991. There is also growing evidence to suggest a relationship between increased non-medical use of opioid analgesics and increased heroin abuse. 2 Use of opioids was almost always preceded by use of alcohol, marijuana, tobacco or other drugs. Among 2012 NYS opioid fatalities, 71% included other drug use. To be successful, efforts targeting opioid abuse problems must also assess the adequacy of efforts to prevent the early initiation of the most popular and available substances of abuse. Communities may adopt a range of prevention activities depending on their specific needs, from primary, universal prevention to prevent non-medical use of opioid analgesics, to indicated prevention to reduce opioid overdoses. Developed by the New York State Department of Health, NYS Office of Alcoholism and Substance Abuse Services, and NYS Office of Mental Health with the New York Academy of Medicine. 1
Table 1: Risk and Protective Factors and Related Interventions Domain Contributing Factors 1 Interventions Availability and access to Rx Opioids Social Access to opioids from peers, parents, family by ignoring the problem or not being vigilant about abuse Secure prescription storage and disposal, public awareness campaigns COMMUNITY Retail Access to opioids through over prescribing, unsafe prescribing, unsafe storage and disposal of prescription drugs Community Norms favorable to substance use such as a perception that the use is a passing phase Low perception of potential harm from Rx opioid use Limited Opportunity Infrastructure e.g. poverty, unstable housing, poor quality housing, lack of neighborhood cohesion, low quality schooling, low or no employment, lack of public safety Community opportunities and rewards for prosocial involvement Laws to reduce availability, Prescription drug monitoring program: I-STOP; prescriber education, Monitoring of multiple medications Media campaigns: social norms change Reducing drug use visible in public places Media campaigns: social norms, link to resources, address conflicting messages in media Advocacy training, System changes that address environmental factors SCHOOL FAMILY Lack of commitment and low school attachment Increased educational opportunities and rewards for Pro-social Involvement Family history of substance abuse Family conflict Favorable family attitudes towards drugs Family engagement and rewards for prosocial Involvement School and Afterschool cultural enrichment, arts, recreational programming; Mentoring Parent skills training, Parent education, Strengthening Families 10-14, Active parenting of Teens, Guiding Good Choices PEER Peer norms favor or reward drug use Friends use drugs/engage in other risk behaviors Mentoring, Community service programs, School and Afterschool cultural enrichment, arts, recreational programming, Outdoor education. INDIVIDUAL Early Initiation of Substance use Poly-substance use Early Initiation of Other Problem behaviors Social and emotional skills competency Unaddressed trauma (Adverse Childhood Experiences) Personality factors: temperament, disposition, coping style Delay onset of use through EBP educational programs like Project Success, Life Skills Training, Too Good for Drugs, Strengthening Families 10-14 Social development, classroom management training for early elementary school teachers, Good Behavior Game, Positive Action, PATHS Recognizing trauma, screening, referrals to trauma informed services, capacity building training for trauma informed services; Project Success, Student Assistance programs, Prevention Counseling Resiliency practices and training of community supporting systems 1 Red factors indicate increased risk; blue factors indicate decreased risk, or protective factors. 2
Environmental Strategies for Substance Abuse Prevention Strategies targeting shared environments have worked to reduce tobacco and alcohol use and should work to reduce prescription opioid abuse. As illustrated in the framework below by Michael Klitzner, 3 change agents in the shared environment can support healthy behaviors and thwart risky behaviors for all youth (and entire populations), regardless of how well prepared or protected the individuals may be by their individualized environments. This perspective takes into account that individuals are influenced by a complex set of factors, such as the rules and regulations of social institutions to which they belong, the norms of their communities, the media messages to which they are exposed and the accessibility of alcohol, tobacco, and prescription drugs. Individualized environments may include families, schools, the faith community, and health care providers. Generally, strategies at this level seek to socialize, instruct, guide, and counsel children in ways that increase their resistance to health risk behaviors. These strategies provide education, skills training, and opportunities for healthy social development through school based curricula, mentoring, education and counseling. Both the environmental strategies targeting shared environments and the programs and services Individualized environments are required to prevent substance abuse and its negative and costly consequences. The five-step Strategic Prevention Framework is outlined in the Action Plan: (1) Assess their prevention needs based on epidemiological data; (2) Build their prevention capacity; (3) Develop a strategic plan; (4) Implement effective community prevention programs, policies, and practices; (5) Evaluate their efforts for outcomes. 3
ACTION: STRATEGIC PREVENTION FRAMEWORK Recommended Steps 1. Assess prevention needs based on epidemiological data Brief Description Review data in the community health improvement plans for needs and gaps Identify needed data sources and develop tools to collect data to fill gaps Identify populations with disparities for risk factors and drug use. These may include youth aged 18 to 25 for non-medical use of prescription drugs, adults over 50 years, veterans and military service members 2. Build prevention capacity Assess community capacity and readiness Identify key leaders and partners for community coalitions Health & MEB Health promotion organizations; Organizations that work with special populations; Law enforcement; Afterschool programs, Recreation centers, clubs; Schools and universities; Community service groups. Health care professionals with prescription writing privileges 3. Develop a strategic plan Work with partners to identify and track intermediate process steps and outcomes Clarify roles of partners 4. Implement prevention strategies & programs (see sub-step below) 4a. Assist with overcoming barriers to implementation 5. Evaluate efforts for outcomes/population impacts (see sub-step below) Implement planned strategies Decrease the availability of prescription pain relievers Improve regulations and policies to decrease availability Increase enforcement efforts of regulations and policies Increase the social disapproval of prescription pain reliever abuse Increase youth perception of adult disapproval Work with partners and stakeholders to identify concerns and challenges they would experience. Common concerns are: Issue may not be perceived as priority or problem; Staff training and equipment needed; Partners may not have the tools to track intermediate outcomes Provide support in multiple ways: Share educational resources; Link with experts in the field; Provide model policies; Provide examples of methods used; Recognize institutions taking steps toward implementation Identify data sources and develop tools/procedures to collect data Monitor changes in process, outcome, impact measures Develop reports and disseminate findings to key stakeholders Modify strategic plan based on evaluation results Monitor implementation 4
ACHIEVEMENT Overarching Objective 2: Objective 2.1.1: By December 31, 2017, reduce the percentage of youth in grades 9-12 reporting the use of alcohol on at least one day for the past 30 days to no more than 34.6%. (Baseline: 38.4 per 100, 2011 YRBS) Tracking Indicator Objective 2.1.2: By December 31, 2017, reduce the percentage of youth ages 12-17 years reporting the use of non-medical use of painkillers. (Baseline: 5.26% 2009-2010, NSDUH, Target: 4.73%) Tracking Indicator Objective 2.1.3: By December 31, 2017, reduce the percentage of adult (age 18 and older) binge drinking (5 drinks or more for men during one occasion, and 4 or more drinks for women during one occasion) during the past month to no more than 18.4%. (Baseline: 20.4 percent, 2011 BRFSS) Tracking Indicator Examples of short-term intermediate outcome measures: Number of retailers who have policies that reduce availability as indicated by Prescription Drug Monitoring Program Percent of young adults, or their caregivers, perception of harm of non-medical use of opioids Use of trauma-informed and trauma-sensitive practices by key organization entities in the community (e.g. healthcare, police, schools, community-based organizations) Examples of short-term process measures: Number of seminars or number and type of education materials distributed Number of new partners/sectors enrolled in sharing system Number of providers trained Number of trainings Examples of short-term process measures: Non-medical use of prescription drugs Use of other substances e.g. alcohol, tobacco Incidence of opioid overdose 5
Figure 1: County-Level Logic Model for Reducing Nonmedical Use of Opioids iv [Insert Overall Problem or Goal Statement Here. This should be specific (Who? What? Where?) and supported by needs assessment data.] Example: Young adults (age 18-25) in X county are at high risk for the non-medical use of opioids County-Identified Contributing Factors Interventions and Inputs Process Measures/ Outputs (Measure of activities from Interventions and Inputs column) Short-Term Outcomes (Changes as a direct result of the Interventions and Inputs ) Intermediate Outcomes (Changes in the Intermediate Variable/ Contributing factor) Long-Term Outcomes (Changes in the Problem Statement) Availability (retail access) to opioids for young adults Sharing of prescription drug monitoring program data across systems create data- sharing systems among key partners1 with a new campaign that provides educational materials and seminars on system use. Develop provider education about the risks of sharing medication, clinical guidelines, and safe prescribing practices # of seminars, # and type of educational materials distributed # of new partners/sectors enrolled in sharing system # of times data is shared # of providers trained # of trainings Increased use of prescription drug monitoring program (PDMP) system, as indicated by an increase in # and type of partners reporting use of PDMP data and in # of times data is shared Providers report increased knowledge of the risks of sharing medication, clinical guidelines, and safe prescribing practices from pre- to post-test Availability (retail access) to opioids for young adults has decreased by X amount in X time, as indicated by PDMP data Non-medical use of opioids for young adults in urban areas in X county are reduced by X% in X years, as indicated by Low perception of harm of use Create and implement a public awareness campaign targeting urban young adults to increase perception of harm # of venues, views, airings, website hits Campaign has adequate reach and dose among young adults, as indicated by 2 X% increase in young adult perception of harm, as indicated by 2 Depending on the design of a state s PDMP, this could be broadened to include not just hospital staff, but also law enforcement and others who might have access to PDMP data. This definition then affects the measurement of the outcomes. (i.e., types of partners is related to types of providers who are able to view the PDMP data in your state, as defined by your state s PDMP.) 3 The short-term outcome for the awareness campaign is an assessment of the campaign s reach and dose. While this may sometimes be considered a process measure, this is a hard-to-reach population where change will require adequate message saturation and time for the message to take root. Increases in perception of harm then becomes the intermediate outcome that logically follows demonstration of adequate reach and dose. 6
These logic models offer two approaches for developing an action plan to address opioid-related problems or goals. Figure 1 addresses the consumption of opioids, with a focus on the non-medical use of prescription opioids. Figure 2 focuses on the consequences of heroin consumption specifically fatal overdose. Because preventing opioid misuse also prevents overdose, we see these two models as overlapping parts of a spectrum of prevention. Depending on the substance of concern (heroin vs. more general opioids), different risk factors may be relevant. Intermediate outcomes in both models can be considered as short-term outcome measures. In addition, we have included sample resources containing information related to strategies and interventions included in the models. Please note that these logic models should only be used as a guide, as the risk factors included will not be present in, or relevant to, all environments. Also, the interventions included are only examples. Additional interventions and inputs might include policy change, bystander-focused interventions, and other targeted educational interventions. Figure 2: County-Level Logic Model to Reduce Opioid Overdose iv [Include overall Problem or Goal Statement Here. This should be specific (Who? What? Where?) and supported by needs assessment data.] Example: Adults (age 35-54) in county Y are at high risk for fatal opioid overdose. County-Identified Contributing Factors Interventions and Inputs Process Measures/ Outputs (Measure of activities from Interventions and Inputs column) Short-Term Outcomes (Changes as a direct result of the Interventions and Inputs ) Intermediate Outcomes (Changes in the Intermediate Variable/ Contributing factor) Long-Term Outcomes (Changes in the Problem Statement) Limited community provider knowledge of and ability to respond to fatal overdose risk factors Training for community providers1 on overdose risk factors, recognition and response Number of new community partners, providers and/or sectors trained Increase in the number of new community partners, providers, and/or sectors who have received training in overdose risk factors, recognition, and response Community providers/ trainees demonstrate improved knowledge of risk factors, recognition and response as demonstrated by Fatal opioid overdose rates for adults in urban areas in Y community are reduced by X in X years, as indicated by 1 This can refer to general providers, also healthcare providers, social service providers, first responders and others, including those who come into contact with those at a high-risk of overdose. Your process outcome would be measured according to which providers you are training. Training on the use of Narcan could be incorporated into this strategy (and should then be reflected in the outcomes columns). 7
Resources Ready to get started? These resources can help. For Communities: Prevention Agenda, Prevent Non-medical Prescription Opioid Use and Overdose Factsheet, September 18, 2015 Prevention Resource Centers To find more information about the PRC in your region, go to http://www.oasas.ny.gov/prevention/cc/prc/index. cfm. NYS Substance Abuse Prevention Coalitions For contact information for an OASAS registered Substance Abuse Prevention Coalition in your community, contact: racheltruckenmiller@oasas.ny.gov. Substance Abuse Prevention Media Campaigns http://captus.samhsa.gov/access-resources/substance-abuse-prevention-media-campaigns This tool offers examples of media campaigns developed by states, jurisdictions, and national organizations to target substance abuse prevention. Opioid Overdose Prevention Education http://www.stopoverdose.org/ The Stop Overdose website, developed by the University of Washington s Alcohol and Drug Abuse Institute, offers education, training, and answers to frequently asked questions about preventing and reversing overdoses and getting the opiate overdose antidote naloxone (Narcan). The Fly Effect Heroin Prevention Campaign from Wisconsin http://theflyeffect.com/ The purpose of the Fly Effect campaign is to raise awareness of heroin s destructive power. Using a variety of media, the campaign shows teens how the decision to take a hit can quickly spiral out of control. More information about the campaign is available at: http://www.doj.state.wi.us/dci/heroin-awareness/fly- effect-heroin-prevention-campaign. Please note that this campaign s evaluation results are unknown. Substance Abuse and Mental Health Services Administration s (SAMHSA): Opioid Overdose Prevention Toolkit http://store.samhsa.gov/product/opioid-overdose-prevention-toolkit/sma13-4742 This toolkit can be used to equip communities and local governments with material to develop policies and practices to help prevent opioid-related overdoses and deaths. The toolkit also addresses issues for first responders, treatment providers, and those recovering from opioid overdose. Harm Reduction Coalition: Overdose Prevention Resources http://harmreduction.org/our-work/overdose-prevention/ The Harm Reduction Coalition provides training and technical assistance on implementation of overdose prevention programs with naloxone distribution. Online resources include information on overdose prevention and risk factors, and on responding to an overdose using naloxone; a comprehensive manual on how to implement an overdose prevention program; and educational materials that can be adapted for program use. PDMP Center for Excellence: http://www.pdmpexcellence.org/ The Center collaborates with a wide variety of PDMP stakeholders, including federal and state governments and agencies, universities, health departments, and medical and pharmacy boards. It is advised by an expert panel of nationally recognized professionals in addiction treatment, pain medicine, public health, and epidemiology. 8
For Healthcare Providers: Responsible Opioid Prescribing: A Clinician s Guide http://www.oasas.ny.gov/prevention/cc/prc/index.cfm. The Federation of State Medical Boards Foundation undertakes educational and scientific research projects designed to expand public and medical professional knowledge and awareness of challenges affecting health care and health care regulation. For more information, contact: Jean Audet, NYS Office of Alcoholism and Substance Abuse Services, Jean.Audet@oasas.ny.gov 1 National Institute on Drug Abuse. Prescription Drug Abuse. http://www.drugabuse.gov/publications/ research-reports/prescription-drugs/opioids/what-are-opioids 2 Substance Abuse and Mental Health Services Administration (SAMHSA), Results from the 2012 National Survey on Drug Use and Health: Summary of National Findings, NSDUH Series H-46, HHS Publication No. (SMA) 13-4795. Rockville, MD: Substance Abuse and Mental Health Services Administration, 2013. 3 SAMHSA. Appendix J. Compendium of Model Program and Best Practices in Prevention. https://captus.samhsa.gov/sites/default/files/handout1compendium_of_model_programs_and_best_practices_in_prevention.pdf 4 Developed under the Substance Abuse and Mental Health Services Administration s Center for the Application of Prevention Technologies task order. Reference #HHSS2832012000241/HHSS28342002T. 5 Ibid. 9