Preventing Opioid Misuse and Use: The Lucky Preventionist s Guide to Strategic Planning 1
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LUCK Where Preparation Meets Opportunity Opioids: Understanding how we got here How History Repeats Some Opiate History 3400 BC First evidence to cultivation and use of opiate poppy plants in Mesopotamia. Sumerians referred to it as the joy plant 357 BC Hippocrates The Father of Medicine documented the usefulness of opiates to treat a variety of internal diseases. In 1806 a German chemist introduces a new derivative of opium which he named after the Greek god of dreams, Morpheus. Morphine quickly becomes a mainstay in medicine and was used widely to treat a variety of conditions including: pain, anxiety, respiratory problems, consumption and women s ailments. 3
Morphine used widely to treat pain from battle injuries during the Civil War Many men returned home from the war with an addiction to morphine, known as soldier s disease Because of the rampant abuse of morphine and the numbers of people who reported being addicted, a safer alternative to morphine was sought Winslow's Soothing Syrup for infants Active Ingredient: Morphine 4
Main Effects of Opiates Pain Blocker/Euphoric Effects Cough Suppressant Constipation...morphinism is a disease, in the majority of cases, initiated, sustained and left uncured by members of the medical profession. Dr. Kennedy Foster, New York Medical Journal 1914 In 1916 German scientists formulate oxycodone as a safe painkilling option to heroin which was now no longer in production 5
If Opioids have been around and an issue for so long, why are they getting so much attention now? Unintentional Drug Overdose Deaths United States, 1970 2007 6
Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over) 1999 ( range 1 50 ) SOURCE: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Treatment Episode Data SET (TEDS). Data received through 11.03.10 <8 8 14 15 18 45 or more 19 44 Incomplete data Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over) 2001 ( range 1 71 ) SOURCE: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Treatment Episode Data SET (TEDS). Data received through 11.03.10 <8 8 14 15 18 45 or more 19 44 Incomplete data Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over) 2003 ( range 2 139 ) SOURCE: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Treatment Episode Data SET (TEDS). Data received through 11.03.10 <8 8 14 15 18 45 or more 19 44 Incomplete data 7
Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over) 2005 ( range 0 214 ) SOURCE: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Treatment Episode Data SET (TEDS). Data received through 11.03.10 <8 8 14 15 18 45 or more 19 44 Incomplete data Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over) 2007 ( range 1 340 ) SOURCE: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Treatment Episode Data SET (TEDS). Data received through 11.03.10 <8 8 14 15 18 45 or more 19 44 Incomplete data Primary non-heroin opiates/synthetics admission rates, by State (per 100,000 population aged 12 and over) 2009 ( range 1 379 ) SOURCE: Center for Behavioral Health Statistics and Quality, Substance Abuse and Mental Health Services Administration, Treatment Episode Data SET (TEDS). Data received through 11.03.10 <8 8 14 15 18 45 or more 19 44 Incomplete data 8
Farm to Lab Where Do Opioids Come From? The Opium Poppy The Opium Poppy Papaver Somniferum Global Picture Where Do Opioids Come From? 9
Opioids Opiates: Semi-Synthetic Synthetic Opium Morphine Codeine Heroin Hydrocodone Hydromorphone Oxycodone Oxymorphone Buprenorphine Fentanyl Methadone Tramadol Opioids Differ Drug Duration Potency Methadone 24-32 hours **** Heroin 6-8 hours ***** Oxycontin 3-6 hours ***** Codeine 3-4 hours * Demerol 2-4 hours ** Morphine 3-6 hours *** Fentanyl 2-4 hours ******** Chart from OOD Prevention & Reversal Trainers Manual-BPHC How Opioids Are Used Ingested pills that are swallowed Snorted heroin or crushed pills Smoked opium or heroin Injected heroin or crushed pills 10
Opioid Receptors in the Brain From MA BSAS OOD Prevention & Reversal Trainers Manual - BPHC Opioid Receptors in the Brain Most Widely-used Opiates in the U.S. Vicodin A powerful pain reliever prescribed for acute episodes of pain (injury, post surgery) and chronic pain. Most abused prescription in the U.S. (Hydrocodone and Acetaminophen) OxyContin A powerful opiate originally formulated to time-release its effects. Easily overridden and abused. New formulations have made OxyContin less desirable on the streets, contributing to an increase in heroin and fentanyl. Heroin The most widely used non-prescription opiate. It is estimated that more than half of people currently using heroin began opiate use from a prescription. 11
Strategic Prevention Framework Prevention "Prevention is an active, assertive process of creating conditions and/or personal attributes that promote the well-being of people. (William A. Lofquist) Prevention Continuum 12
Behavioral Health Continuum of Care 5 Promotion Institute of Medicine (IOM) What are we trying to prevent? Opioid (Heroin, Oxycontin, etc) First Use (50%) AND Abuse (50%) Most commonly used opioids Heroin Codeine Demerol Morphine Darvocet Fentanyl Dilaudid Methadone Opium Hydrocodone Oxycodone Levorphanol Vicodin OxyContin Tylenol 3 Tylox Percocet Percodan 13
Key Principles of the SPF Public Health Approach Data-Driven Community-Based Strategic Planning Process Outcomes-Based Prevention Assessment Diagnosis: Needs and risk & protective factors assessment Resource inventory Prioritization of community issues Resource Inventory Current community resources Who is being serviced Overlaps vs. gaps Increase Collaboration Decrease Duplication 14
Levels Establish baseline Data Analysis Trends Over time Patterns By age, gender, race/ethnicity 1 2 3 Synthesize all 3 sources of data and resource inventory Identify areas of focus Craft problem statements Drug (or other issue) Target population Baseline rate Prioritization of Community Issues Build an inclusive coalition/community movement Capacity Building: The ability to mobilize community & resources Membership Structure/function Engage community, include key decision makers & those affected by the problem 15
Sample Organizational Chart Steering Committee General Membership Community X workgroup Community Y workgroup Community Z workgroup Capacity Building Educate the group Leadership Effective prevention Cultural competence Capacity Building Identify and secure resources Human resources Technical resources Management and evaluation resources Financial resources 16
Planning Data- driven (based on diagnosis) Multiple strategies in multiple domains Evidence based (policy, practice, system change) Logical Planning What is a Comprehensive Strategic Plan? Vision & Mission Statements Problem Statement & Summary of Data Strategic Goals & Objectives Intervening Variables & Outcomes Logic Models Evidence-Based Strategies Action Plan & Timeline Evaluation Plan Planning Logic Model: Logical connection between the problem, the Risk & Protective Factors and Strategies Implemented Related Problems Substance Use High Rates of Binge Drinking High Rates of Drinking and Driving Risk & Protective Factors Early Initiation of Alcohol Use Social Norms Encouraging Binge Drinking Little Enforcement of Drinking and Driving Strategies High Rate of Youth Alcohol- Related Crashes Communitybased recreation opportunities Media campaign in school to correct perceptions of normal consumption Enforcement Checkpoints 17
Implementation Putting your plans into practice Multiple strategies in multiple domains Fidelity Staffing 5. Evaluation Monitor progress and impact on selected change indicators Community is unit of analysis not the individual Trends over time Use evaluation results to realign strategies, as needed Cultural Competence Meets the Needs of the People With Whom You Are Working Eliminates service & participation disparities Improves effectiveness & quality of programs, policies and practices 18
Sustainability Sustain outcomes, not necessarily programs Think sustainability from the beginning Look to community resources to sustain outcomes Sustain prevention by making it everyone s job Contact Information Carl J. Alves carljalves@gmail.com 19