Reducing the Risk of Opioid Poisoning: Evaluation of a Community Based Approach Doug Easterling ( Jessica Pockey Y. Montez Lane Wake Forest School of Medicine Wake Forest School of Medicine November 2, 2011

Evaluation of Multi-Strategy Community Initiatives: Options Macro Evaluation (for multi-site initiatives) Macro Evaluation (for multi-site initiatives) Local Evaluation Local Evaluation Scope of evaluation Scope of evaluation Overall initiative Overall initiative All components of strategy All components of strategy Process Process Theory Theory Individual programs / strategies Individual programs / strategies Type of evaluation work Type of evaluation work Articulation of program components and mapping of logic Articulation of program components and mapping of logic “Research” – data collection and analysis “Research” – data collection and analysis Facilitate learning Facilitate learning Program refinement Program refinement Implications for replication Implications for replication

Context for Presentation Evaluation work associated with a community-based initiative to reduce substance abuse (particularly prescription-drug abuse) within Wilkes County, North Carolina Evaluation work associated with a community-based initiative to reduce substance abuse (particularly prescription-drug abuse) within Wilkes County, North Carolina

Additional Info on Overdose Data Wilkes County has one of the highest drug overdose death rates in the country Wilkes County has one of the highest drug overdose death rates in the country Nearly all of these deaths are due to prescription opioids (long- acting and short-acting) Nearly all of these deaths are due to prescription opioids (long- acting and short-acting) Decedents are a mixture of “legitimate” patients taking medications incorrectly (misuse) and those seeking euphoria (abuse) and those self-medicating for uncontrolled pain Decedents are a mixture of “legitimate” patients taking medications incorrectly (misuse) and those seeking euphoria (abuse) and those self-medicating for uncontrolled pain Many decedents had filled a prescription from a pharmacy in the months prior to death, indicating the need for physician education, and representing a missed opportunity for patient/drug user education Many decedents had filled a prescription from a pharmacy in the months prior to death, indicating the need for physician education, and representing a missed opportunity for patient/drug user education

Chronic Pain Initiative (CPI) A Multi-Pronged Strategy to Prevent Opioid Abuse in Wilkes County, NC A Multi-Pronged Strategy to Prevent Opioid Abuse in Wilkes County, NC Strategies developed and implemented by a broad-based community coalition Strategies developed and implemented by a broad-based community coalition Substance Abuse Task Force Substance Abuse Task Force Northwest Community Care Network Northwest Community Care Network Wilkes Co. Health Department Wilkes Co. Health Department Wilkes Healthy Carolinians Council Wilkes Healthy Carolinians Council United Way and partner Agencies United Way and partner Agencies Wilkes Regional Medical Center and Practicing Physicians Wilkes Regional Medical Center and Practicing Physicians Wilkes Ministerial Association Wilkes Ministerial Association New River Behavioral Health Center New River Behavioral Health Center Wilkes Co. Sheriff’s Office and Town Police Dept’s. Wilkes Co. Sheriff’s Office and Town Police Dept’s. Parents and teens Parents and teens Child Abuse Prevention Team Child Abuse Prevention Team Wilkes Co. Schools Wilkes Co. Schools Wilkes Community College Wilkes Community College SAFE (Family Shelter; Domestic Violence) SAFE (Family Shelter; Domestic Violence) Leadership and funding from Northwest Community Care Network Leadership and funding from Northwest Community Care Network

CPI Strategies Educate providers to limit the prescribing of opioids Educate providers to limit the prescribing of opioids Increase the use of Pain Agreements Increase the use of Pain Agreements Increase the use of the Controlled Substances Reporting System (CSRS) among providers and pharmacists – to reduce access for chronic abusers Increase the use of the Controlled Substances Reporting System (CSRS) among providers and pharmacists – to reduce access for chronic abusers Provide chronic pain patients with new resources to manage pain (special focus on Medicaid patients and ER patients) Provide chronic pain patients with new resources to manage pain (special focus on Medicaid patients and ER patients) Enact policies to limit the prescribing of opioids within the local hospital (special focus on ER) Enact policies to limit the prescribing of opioids within the local hospital (special focus on ER) Increase the availability of Naloxone to mitigate the effects of overdose (Project Lazarus) Increase the availability of Naloxone to mitigate the effects of overdose (Project Lazarus) Community education and awareness-raising on risks and resources Community education and awareness-raising on risks and resources More coordinated investigation and response by law enforcement More coordinated investigation and response by law enforcement Data monitoring (e.g., vital statistics, dispensing of controlled substances, autopsy reports) Data monitoring (e.g., vital statistics, dispensing of controlled substances, autopsy reports) Coalition meetings and project management Coalition meetings and project management

1. Community knowledge; Coalition building 2. Epidemiologic Monitoring 3. Prevention: Chronic Pain Initiative; Treatment 4.Rescue: Project Lazarus; Treatment 5. Program Evaluation: process and outcomes 9 Conceptual Model for Wilkes County Approach to Reducing Substance Abuse

Evaluation Scope of Work Clarify the “program model” for CPI Clarify the “program model” for CPI Intentions and expectations Intentions and expectations Key components and activities Key components and activities Pathways through which activities achieve expected outcomes Pathways through which activities achieve expected outcomes Assess who is actually being reached Assess who is actually being reached CP patients CP patients Providers Providers Assess how the program is operating in practice Assess how the program is operating in practice Evaluate the potential effectiveness of the model Evaluate the potential effectiveness of the model Set the stage for: Set the stage for: Refining the CPI model Refining the CPI model Replication at other sites Replication at other sites More definitive evaluation studies More definitive evaluation studies

Initial Evaluation Task: Case Management of at-risk Medicaid patients Nature of the Program Nature of the Program Identify Medicaid pts within NCCN who are being prescribed narcotics and are at risk for abuse/misuse Identify Medicaid pts within NCCN who are being prescribed narcotics and are at risk for abuse/misuse Pharmacy report generated by NC DMA Pharmacy report generated by NC DMA Determine which patients are still enrolled in NCCN Determine which patients are still enrolled in NCCN Identify each patient’s PCP Identify each patient’s PCP Visit PCP and request medical records Visit PCP and request medical records Determine if patient meets eligibility criteria Determine if patient meets eligibility criteria Notify patients’ PCP with expectation that PCP will more carefully manage pts Notify patients’ PCP with expectation that PCP will more carefully manage pts Case manager contacts identified pts and provides guidance, referrals, support Case manager contacts identified pts and provides guidance, referrals, support Ongoing follow-up by Case Manager Ongoing follow-up by Case Manager Support Group for identified patients Support Group for identified patients Evaluation Questions Evaluation Questions How many patients are actually being reached? How many patients are actually being reached? How many eligible patients are not being reached? How many eligible patients are not being reached? What services are participants actually receiving? What services are participants actually receiving? Can the data collected by the Case Managers tell us anything about individual-level changes in medication use and/or utilization of health care (esp. ED)? Can the data collected by the Case Managers tell us anything about individual-level changes in medication use and/or utilization of health care (esp. ED)?

Evaluation Methods In-depth interviews with case managers In-depth interviews with case managers To learn what the process looks like in practice To learn what the process looks like in practice Create a Flow Chart indicating how NCCN patients get into the program and where they fall out Create a Flow Chart indicating how NCCN patients get into the program and where they fall out Review data collected by case managers (excel files) Review data collected by case managers (excel files)

Key Findings on CM Program Extremely time-consuming to review data reports from state and medical records from PCPs Extremely time-consuming to review data reports from state and medical records from PCPs Many PCPs were doing enhanced monitoring of identified patients even before they were alerted by CM Many PCPs were doing enhanced monitoring of identified patients even before they were alerted by CM Many patients declined the case management services (actively or passively) Many patients declined the case management services (actively or passively) Selection bias at odds with intent of program Selection bias at odds with intent of program Case management turned out to be much lighter than presumed Case management turned out to be much lighter than presumed Only telephone calls / No home visits Only telephone calls / No home visits Calls focused primarily on collecting data (e.g., pain severity) Calls focused primarily on collecting data (e.g., pain severity) No real counseling or care coordination No real counseling or care coordination Only a couple support groups had been held and no one attended Only a couple support groups had been held and no one attended

What happened next? NCCN decided that CM program was not worth the investment. Stopped recruiting patients. NCCN decided that CM program was not worth the investment. Stopped recruiting patients. Pay more attention to the possibility that PCPs were doing enhanced management of all chronic pain patients Pay more attention to the possibility that PCPs were doing enhanced management of all chronic pain patients Why? Why? Shift evaluation focus to the Physician Toolkit – presumed to be the impetus to changes in provider behavior. Shift evaluation focus to the Physician Toolkit – presumed to be the impetus to changes in provider behavior.

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Contents of the Toolkit General information General information Managing chronic pain Managing chronic pain Proper prescription writing Proper prescription writing Precautions Precautions Tools for managing chronic pain patients Tools for managing chronic pain patients Algorithm for assessing and managing pain Algorithm for assessing and managing pain Pain Contract / Treatment Agreement Pain Contract / Treatment Agreement Format for progress notes Format for progress notes Medication flowsheet Medication flowsheet Personal care plan Personal care plan Functional Ability Questionnaire (FAQ) Functional Ability Questionnaire (FAQ) Patient education materials Patient education materials

Intent of Physician Education Promote a more deliberate approach to managing chronic pain patients Promote a more deliberate approach to managing chronic pain patients Encourage more discretion and data-collection by provider before prescribing opioids to a particular patient Encourage more discretion and data-collection by provider before prescribing opioids to a particular patient Greater use of Pain Agreement (to limit the number of providers and pharmacists that patients access) Greater use of Pain Agreement (to limit the number of providers and pharmacists that patients access) Reduce access to opioids among abusers, while ensuring that patients’ legitimate medical needs are met Reduce access to opioids among abusers, while ensuring that patients’ legitimate medical needs are met

Provider Education Intervention The intervention was more than the notebook The intervention was more than the notebook County Medical Director has educated 29 medical professionals in 15 practices in Wilkes County (focusing on practices with high numbers of chronic pain patients) County Medical Director has educated 29 medical professionals in 15 practices in Wilkes County (focusing on practices with high numbers of chronic pain patients) Presents general information on substance use issue in Wilkes Co. Presents general information on substance use issue in Wilkes Co. Stresses the importance of proper management of chronic pain patients Stresses the importance of proper management of chronic pain patients Provides copy of the Physician Toolkit and reviews the content Provides copy of the Physician Toolkit and reviews the content

Evaluation Questions 1. To what extent is the Physician Toolkit being used by the providers who were trained by the County Medical Director? 2. How much have the providers changed their approach to managing chronic pain patients (taking into account their prior practice)? 3. What are the strengths and weaknesses of the different tools in the Toolkit? 4. How are patients responding to whatever changes in practice are occurring?

Evaluation Methods Structured, in-person interviews with providers who received a Toolkit and were educated by the County Medical Director Structured, in-person interviews with providers who received a Toolkit and were educated by the County Medical Director Interviews asked about use and usefulness of Toolkit components, as well as other aspects of treating chronic pain patients Interviews asked about use and usefulness of Toolkit components, as well as other aspects of treating chronic pain patients Interviews lasted minutes Interviews lasted minutes Attempted to recruit all providers (physicians, PAs, NPs) who were exposed to the intervention at least one year earlier Attempted to recruit all providers (physicians, PAs, NPs) who were exposed to the intervention at least one year earlier Excluded providers who do not see chronic pain patients Excluded providers who do not see chronic pain patients

Study Population # who have been trained Attempted to Recruit Interviewed TotalPrior to Jan 2009 Physicians Phys Assts 4333 Nurse Practitioners 4333 TOTAL

Use of the Physician Toolkit among the 14 Providers Pattern# Providers Currently using multiple CPI tools, and at least one was put into practice because of the intervention 7 Currently using multiple CPI tools, but all were in practice prior to the intervention 1 Using only one CPI tool (Pain Contract) – in place prior to the intervention 4 Not using any CPI tool2

Use of Specific Toolkit Components

Other Impacts of the Intervention Change in the use of Pain Agreement among 4 of the 8 providers who were already using a Pain Agreement Change in the use of Pain Agreement among 4 of the 8 providers who were already using a Pain Agreement 1 provider reported that they switched to the CPI Agreement 1 provider reported that they switched to the CPI Agreement 3 other providers reported greater use of Agreement 3 other providers reported greater use of Agreement Use of CSRS Use of CSRS 1 provider reported that CPI caused him/her to begin using CSRS 1 provider reported that CPI caused him/her to begin using CSRS 2 other providers reported that CPI led to increased use 2 other providers reported that CPI led to increased use Other changes in practice or policy Other changes in practice or policy No more post-dating of scripts or writing early refills (n=2) No more post-dating of scripts or writing early refills (n=2) Mandatory drug testing Mandatory drug testing Don’t allow patients to have multiple prescribers within practice Don’t allow patients to have multiple prescribers within practice Require patients to show ID when picking up meds Require patients to show ID when picking up meds Adopted a multi-dimensional approach to working with chronic pain patients Adopted a multi-dimensional approach to working with chronic pain patients Better documentation Better documentation

“Has your comfort level with treating chronic pain patients changed as a result of being involved in CPI?“ Already had philosophy and was using Already had philosophy and was using pain contract, but CPI validated those tactics pain contract, but CPI validated those tactics and provided documentation tools to ensure they're covering selves. Feels like now there's a guideline explaining Feels like now there's a guideline explaining all that needs to be done. Feels 'covered' if following guidelines. Improved - given good tools, knowledge Improved - given good tools, knowledge Feels more confident treating CP. Pain contract gives patients accountability for meds. Feels more confident treating CP. Pain contract gives patients accountability for meds. Appreciates guidelines, documentation tools, and CSRS for compliance checks. Appreciates guidelines, documentation tools, and CSRS for compliance checks. Other ways that CPI affected providers: Better interactions with patients

Changes in the Pattern of Overdose Death in Wilkes County Unintentional poisoning deaths declined from 31 in 2009 to 19 in 2010 Among those who died of drug overdose in 2010, only 10% had received a prescription for the implicated substance (down from 82% in 2008)

Replication Considerable interest exists throughout NC (and beyond) in replicating some or all the aspects of the Wilkes County approach Considerable interest exists throughout NC (and beyond) in replicating some or all the aspects of the Wilkes County approach The effort currently under discussion by NCCCN and the Governor’s Institute on Alcohol & Substance Abuse would focus on CPI The effort currently under discussion by NCCCN and the Governor’s Institute on Alcohol & Substance Abuse would focus on CPI especially the Physician Toolkit, expanded use of CSRS, and stricter ED policies on dispensing narcotics. especially the Physician Toolkit, expanded use of CSRS, and stricter ED policies on dispensing narcotics. How do we replicate CPI in other communities? How do we replicate CPI in other communities? First look at how CPI came into being within Wilkes County First look at how CPI came into being within Wilkes County Should we try to prompt the same process in other communities? Should we try to prompt the same process in other communities? Or can we leapfrog the community-problem solving process and move straight to implementing best practices / promising practices? Or can we leapfrog the community-problem solving process and move straight to implementing best practices / promising practices?

Key ingredients in the Wilkes Co. approach A sense of urgency among local actors who have influence A sense of urgency among local actors who have influence The problem of prescription-drug misuse must be severe enough to attract attention and to motivate action The problem of prescription-drug misuse must be severe enough to attract attention and to motivate action Establishment (or prior existence) of a community coalition that is able to develop and implement effective strategies to reduce substance use Establishment (or prior existence) of a community coalition that is able to develop and implement effective strategies to reduce substance use Dedicated manager of the coalition with skills in process and content Dedicated manager of the coalition with skills in process and content Appropriate strategy for achieving a change in prevailing medical practice re: treatment of chronic pain patients Appropriate strategy for achieving a change in prevailing medical practice re: treatment of chronic pain patients Tailored to local conditions Tailored to local conditions Includes education on the extent of the problem in the community and the role of providers in limiting supply and opportunities for diversion Includes education on the extent of the problem in the community and the role of providers in limiting supply and opportunities for diversion Includes useful tools that providers can adopt (e.g., Medication Agreements, guidelines for proper script writing) Includes useful tools that providers can adopt (e.g., Medication Agreements, guidelines for proper script writing) Explicit recommendations for hospital policies that limit dispensing of narcotics (especially to ED patients) Explicit recommendations for hospital policies that limit dispensing of narcotics (especially to ED patients) Take advantage of leverage points in larger environment (e.g., CSRS, Medicaid lock-in policy) Take advantage of leverage points in larger environment (e.g., CSRS, Medicaid lock-in policy) Makes good use of various partners in carrying out strategies Makes good use of various partners in carrying out strategies Public health department – multiple strategies Public health department – multiple strategies County Medical Director – to reach physicians and ED County Medical Director – to reach physicians and ED Medical providers – to change their own practice and educate other providers Medical providers – to change their own practice and educate other providers Pharmacist – to other pharmacies in community Pharmacist – to other pharmacies in community Law enforcement Law enforcement Schools Schools

Is it essential to go through such a lengthy process? Or alternatively, can the CPI strategies be disseminated directly into practice at the local level?

Alternative Strategies for Replicating CPI 1. Centralized dissemination  Push out the toolkits through statewide and regional networks of health care professionals (e.g., CCNC) 2. Replicate the Wilkes County process  Foster locally based planning and strategy- development

How did CPI take shape in Wilkes County?

High local rates of: Overdoses Accidental poisoning deaths Misuse of prescription drugs

High local rates of: Overdoses Accidental poisoning deaths Misuse of prescription drugs Sense of Urgency in Community

High local rates of: Overdoses Accidental poisoning deaths Misuse of prescription drugs Sense of Urgency in Community Law enforcement Public health Social services Criminal justice Residents Pharmacists Medical professionals Schools Mental Health SA Tx Providers

High local rates of: Overdoses Accidental poisoning deaths Misuse of prescription drugs Sense of Urgency in Community Healthy Carolinians Coalition Law enforcement Public health Social services Criminal justice Residents Pharmacists Medical professionals Schools Mental Health SA Tx Providers

High local rates of: Overdoses Accidental poisoning deaths Misuse of prescription drugs Sense of Urgency in Community Substance Abuse Coalition Law enforcement Public health Social services Criminal justice Residents Pharmacists Medical professionals Schools Mental Health SA Tx Providers NCCN acted as convener

High local rates of: Overdoses Accidental poisoning deaths Misuse of prescription drugs Sense of Urgency in Community Substance Abuse Coalition Law enforcement Public health Social services $ from NCCN and other funders Criminal justice Residents Pharmacists Medical professionals Schools Mental Health SA Tx Providers Community Organizer

High local rates of: Overdoses Accidental poisoning deaths Misuse of prescription drugs Sense of Urgency in Community Substance Abuse Coalition Law enforcement Public health Social services $ from NCCN and other funders Criminal justice Residents Pharmacists Medical professionals Schools Mental Health SA Tx Providers Team Building data Community Organizer

High local rates of: Overdoses Accidental poisoning deaths Misuse of prescription drugs Sense of Urgency in Community Substance Abuse Coalition Law enforcement Public health Social services $ from NCCN and other funders Criminal justice Residents Pharmacists Analysis Planning Strategy development Medical professionals Schools Mental Health SA Tx Providers Team Building data Community Organizer

High local rates of: Overdoses Accidental poisoning deaths Misuse of prescription drugs Sense of Urgency in Community Substance Abuse Coalition Law enforcement Public health Social services $ from NCCN and other funders Criminal justice Residents Pharmacists Analysis Planning Strategy development Locally relevant strategy for improving treatment of chronic pain patients Medical professionals Schools Mental Health SA Tx Providers Team Building data Community Organizer

High local rates of: Overdoses Accidental poisoning deaths Misuse of prescription drugs Sense of Urgency in Community Substance Abuse Coalition Law enforcement Public health Social services $ from NCCN and other funders Criminal justice Residents Pharmacists Analysis Planning Strategy development Locally relevant strategy for improving treatment of chronic pain patients Locally relevant strategies for Raising public awareness, Communicating risk & Supporting at-risk residents Medical professionals Schools Mental Health SA Tx Providers Team Building data Community Organizer

High local rates of: Overdoses Accidental poisoning deaths Misuse of prescription drugs Sense of Urgency in Community Substance Abuse Coalition Law enforcement Public health Social services $ from NCCN and other funders Criminal justice Residents Pharmacists Analysis Planning Strategy development Locally relevant strategy for improving treatment of chronic pain patients Locally relevant strategies for Raising public awareness, Communicating risk & Supporting at-risk residents Tool Kit Medical professionals Schools Educator with Credibility among Medical community Mental Health SA Tx Providers Team Building data Community Organizer

High local rates of: Overdoses Accidental poisoning deaths Misuse of prescription drugs Sense of Urgency in Community Substance Abuse Coalition Law enforcement Public health Social services $ from NCCN and other funders Criminal justice Residents Pharmacists Analysis Planning Strategy development Locally relevant strategy for improving treatment of chronic pain patients Locally relevant strategies for Raising public awareness, Communicating risk & Supporting at-risk residents Tool Kit Medical professionals Schools Educator with Credibility among Medical community Mental Health SA Tx Providers New knowledge New awareness Motivation to change New tools Team Building data Community Organizer

High local rates of: Overdoses Accidental poisoning deaths Misuse of prescription drugs Sense of Urgency in Community Substance Abuse Coalition Law enforcement Public health Social services $ from NCCN and other funders Criminal justice Residents Pharmacists Analysis Planning Strategy development Locally relevant strategy for improving treatment of chronic pain patients Locally relevant strategies for Raising public awareness, Communicating risk & Supporting at-risk residents Tool Kit Medical professionals Schools Educator with Credibility among Medical community Change in Practice Change in Org Policy Mental Health SA Tx Providers New knowledge New awareness Motivation to change New tools Health Care Organizations Team Building data Community Organizer

High local rates of: Overdoses Accidental poisoning deaths Misuse of prescription drugs Sense of Urgency in Community Substance Abuse Coalition Law enforcement Public health Social services $ from NCCN and other funders Criminal justice Residents Pharmacists Analysis Planning Strategy development Locally relevant strategy for improving treatment of chronic pain patients Locally relevant strategies for Raising public awareness, Communicating risk & Supporting at-risk residents Tool Kit CSRS Medical professionals Schools Educator with Credibility among Medical community Change in Practice Change in Org Policy Mental Health SA Tx Providers New knowledge New awareness Motivation to change New tools Health Care Organizations Team Building data Community Organizer

High local rates of: Overdoses Accidental poisoning deaths Misuse of prescription drugs Sense of Urgency in Community Substance Abuse Coalition Law enforcement Public health Social services $ from NCCN and other funders Criminal justice Residents Pharmacists Analysis Planning Strategy development Locally relevant strategy for improving treatment of chronic pain patients Locally relevant strategies for Raising public awareness, Communicating risk & Supporting at-risk residents Tool Kit CSRS Medical professionals Schools Educator with Credibility among Medical community Change in Practice Change in Org Policy Mental Health SA Tx Providers New knowledge New awareness Motivation to change New tools Health Care Organizations Advocate changes in policy & practice For hospital ED Team Building data Community Organizer

High local rates of: Overdoses Accidental poisoning deaths Misuse of prescription drugs Sense of Urgency in Community Substance Abuse Coalition Law enforcement Public health Social services $ from NCCN and other funders Criminal justice Residents Pharmacists Analysis Planning Strategy development Locally relevant strategy for improving treatment of chronic pain patients Locally relevant strategies for Raising public awareness, Communicating risk & Supporting at-risk residents Tool Kit CSRS Medical professionals Schools Educator with Credibility among Medical community Change in Practice Change in Org Policy Mental Health SA Tx Providers New knowledge New awareness Motivation to change New tools Health Care Organizations Advocate changes in policy & practice For hospital ED Team Building data Community Organizer

High local rates of: Overdoses Accidental poisoning deaths Misuse of prescription drugs Sense of Urgency in Community Substance Abuse Coalition Law enforcement Public health Social services $ from NCCN and other funders Criminal justice Residents Pharmacists Analysis Planning Strategy development Locally relevant strategy for improving treatment of chronic pain patients Locally relevant strategies for Raising public awareness, Communicating risk & Supporting at-risk residents Tool Kit CSRS Medical professionals Schools Educator with Credibility among Medical community Change in Practice Change in Org Policy Mental Health SA Tx Providers New knowledge New awareness Motivation to change New tools Reduction in: supply diversion demand harm Improved care for pain pts OUTCOMES Health Care Organizations Advocate changes in policy & practice For hospital ED Team Building data Community Organizer

High local rates of: Overdoses Accidental poisoning deaths Misuse of prescription drugs Sense of Urgency in Community Substance Abuse Coalition Law enforcement Public health Social services $ from NCCN and other funders Criminal justice Residents Pharmacists Analysis Planning Strategy development Locally relevant strategy for improving treatment of chronic pain patients Locally relevant strategies for Raising public awareness, Communicating risk & Supporting at-risk residents Tool Kit CSRS Medical professionals Schools Increased perception of Risk associated with Prescription drugs Widespread recognition of scope of problem in community New law enforcement strategies Increased availability and awareness For Naloxone Educator with Credibility among Medical community Change in Practice Change in Org Policy Mental Health SA Tx Providers New knowledge New awareness Motivation to change New tools Reduction in: supply diversion demand harm Improved care for pain pts OUTCOMES Health Care Organizations Advocate changes in policy & practice For hospital ED Team Building data Community Organizer

High local rates of: Overdoses Accidental poisoning deaths Misuse of prescription drugs Sense of Urgency in Community Substance Abuse Coalition Law enforcement Public health Social services $ from NCCN and other funders Criminal justice Residents Pharmacists Analysis Planning Strategy development Locally relevant strategy for improving treatment of chronic pain patients Locally relevant strategies for Raising public awareness, Communicating risk & Supporting at-risk residents Tool Kit CSRS Medical professionals Schools Increased perception of Risk associated with Prescription drugs Widespread recognition of scope of problem in community New law enforcement strategies Increased availability and awareness For Naloxone Educator with Credibility among Medical community Change in Practice Change in Org Policy Mental Health SA Tx Providers New knowledge New awareness Motivation to change New tools Reduction in: supply diversion demand harm Improved care for pain pts OUTCOMES Health Care Organizations Advocate changes in policy & practice For hospital ED Team Building data Community Organizer

High local rates of: Overdoses Accidental poisoning deaths Misuse of prescription drugs Sense of Urgency in Community Substance Abuse Coalition Law enforcement Public health Social services $ from NCCN and other funders Criminal justice Residents Community Organizer Pharmacists Analysis Planning Strategy development Locally relevant strategy for improving treatment of chronic pain patients Locally relevant strategies for Raising public awareness, Communicating risk & Supporting at-risk residents Tool Kit CSRS Medical professionals Schools Increased perception of Risk associated with Prescription drugs Widespread recognition of scope of problem in community New law enforcement strategies Increased availability and awareness For Naloxone Educator with Credibility among Medical community Change in Practice Change in Org Policy Mental Health SA Tx Providers New knowledge New awareness Motivation to change New tools Reduction in: supply diversion demand harm Improved care for pain pts OUTCOMES Health Care Organizations Advocate changes in policy & practice For hospital ED Team Building data

High local rates of: Overdoses Accidental poisoning deaths Misuse of prescription drugs Sense of Urgency in Community Substance Abuse Coalition Law enforcement Public health Social services $ from NCCN and other funders Criminal justice Residents Community Organizer Pharmacists Analysis Planning Strategy development Locally relevant strategy for improving treatment of chronic pain patients Locally relevant strategies for Raising public awareness, Communicating risk & Supporting at-risk residents Tool Kit CSRS Medical professionals Schools Increased perception of Risk associated with Prescription drugs Widespread recognition of scope of problem in community New law enforcement strategies Increased availability and awareness For Naloxone Educator with Credibility among Medical community Change in Practice Change in Org Policy Mental Health SA Tx Providers New knowledge New awareness Motivation to change New tools Reduction in: supply diversion demand harm Improved care OUTCOMES Health Care Organizations Advocate changes in policy & practice For hospital ED Team Building data Reduction in: Misuse Overdose Deaths