State of Oklahoma Office of Management and Enterprise Services Solicitation Central Purchasing Division

1. Solicitation #: 2. Solicitation Issue Date:

3. Brief Description of Requirement:

4. Response Due Date1: Time: 3 p.m. CST/CDT

5. Issued By and RETURN SEALED BID TO:

Personal, U.S. Postal or Common Carrier Delivery: Office of Management and Enterprise Services Central Purchasing Division Will Rogers Building 2401 N. Lincoln Blvd, Suite 116, Oklahoma City, OK 73105

6. Solicitation Type (check one below):

Invitation to Bid Request for Proposal Request for Quote

7. Requesting Agency:

8. Contracting Officer: Name: Phone: (405) Email:

1 Amendments to solicitation may change the Response Due Date (read CP GENERAL PROVISIONS, section 3, “Solicitation Amendments”) OMES-FORM-CP-070 (08/2014) PAGE 1 OF 1

State of Oklahoma Office of Management and Enterprise Services Responding Bidder Information Central Purchasing Division

“Certification for Competitive Bid and Contract” MUST be submitted along with the response to the Solicitation.

1. RE: Solicitation #

2. Bidder General Information: FEI / SSN : VEN ID: Company Name:

3. Bidder Contact Information: Address: City: State: Zip Code: Contact Name: Contact Title: Phone #: FAX#: Email: Website:

4. Oklahoma Sales Tax Permit2: YES – Permit #: NO – Exempt pursuant to Oklahoma Laws or Rules

5. Registration with the Oklahoma Secretary of State: YES - Filing Number: NO - Prior to the contract award, the successful bidder will be required to register with the Secretary of State or must attach a signed statement that provides specific details supporting the exemption the supplier is claiming (www.sos.ok.gov or 405-521-3911).

6. Workers’ Compensation Insurance Coverage: Bidder is required to provide with the bid a certificate of insurance showing proof of compliance with the Oklahoma Workers’ Compensation Act. YES – include a certificate of insurance with the bid NO - attach a signed statement that provides specific details supporting the exemption you are claiming from the Workers’ Compensation Act (Note: Pursuant to Attorney General Opinion #07-8, the exemption from 85 O.S. 2011, § 311 applies only to employers who are natural persons, such as sole proprietors, and does not apply to employers who are entities created by law, including but not limited to corporations, partnerships and limited liability companies.)3

Authorized Signature Date

Printed Name Title

2 For frequently asked questions concerning Oklahoma Sales Tax Permit, see http://www.tax.ok.gov/faq/faqbussales.html 3 For frequently asked questions concerning workers’ compensation insurance, see http://www.ok.gov/oid/faqs.html#c221

OMES-FORM-CP-076 (02/2013) SOLICITATION PACKAGE PAGE 2

State of Oklahoma Certification for Competitive Office of Management and Enterprise Services Bid and/or Contract Central Purchasing Division (Non-Collusion Certification)

NOTE: A certification shall be included with any competitive bid and/or contract exceeding $5,000.00 submitted to the State for goods or services.

Solicitation or Purchase Order #: Supplier Legal Name:

SECTION I [74 O.S. § 85.22]: A. For purposes of competitive bid, 1. I am the duly authorized agent of the above named bidder submitting the competitive bid herewith, for the purpose of certifying the facts pertaining to the existence of collusion among bidders and between bidders and state officials or employees, as well as facts pertaining to the giving or offering of things of value to government personnel in return for special consideration in the letting of any contract pursuant to said bid; 2. I am fully aware of the facts and circumstances surrounding the making of the bid to which this statement is attached and have been personally and directly involved in the proceedings leading to the submission of such bid; and 3. Neither the bidder nor anyone subject to the bidder's direction or control has been a party: a. to any collusion among bidders in restraint of freedom of competition by agreement to bid at a fixed price or to refrain from bidding, b. to any collusion with any state official or employee as to quantity, quality or price in the prospective contract, or as to any other terms of such prospective contract, nor c. in any discussions between bidders and any state official concerning exchange of money or other thing of value for special consideration in the letting of a contract, nor d. to any collusion with any state agency or political subdivision official or employee as to create a sole-source acquisition in contradiction to Section 85.45j.1 of this title. B. I certify, if awarded the contract, whether competitively bid or not, neither the contractor nor anyone subject to the contractor’s direction or control has paid, given or donated or agreed to pay, give or donate to any officer or employee of the State of Oklahoma any money or other thing of value, either directly or indirectly, in procuring this contract herein. SECTION II [74 O.S. § 85.42]: For the purpose of a contract for services, the supplier also certifies that no person who has been involved in any manner in the development of this contract while employed by the State of Oklahoma shall be employed by the supplier to fulfill any of the services provided for under said contract.

The undersigned, duly authorized agent for the above named supplier, by signing below acknowledges this certification statement is executed for the purposes of: the competitive bid attached herewith and contract, if awarded to said supplier; OR the contract attached herewith, which was not competitively bid and awarded by the agency pursuant to applicable Oklahoma statutes.

Supplier Authorized Signature Certified This Date

Printed Name Title

Phone Number Email

Fax Number

OMES-FORM-CP-004 (08/2014) PAGE 1 OF 1 TABLE OF CONTENTS

A GENERAL PROVISIONS ...... 4 B. SPECIAL PROVISIONS ...... 10 C. SOLICITATION SPECIFICATIONS ...... 17 D. EVALUATION ...... 25 E. INSTRUCTIONS TO BIDDER ...... 25 F. CHECKLIST ...... 25 G. OTHER ...... 30 H. PRICE AND COST ...... 30

OMES/CENTRAL PURCHASING DIVISION – TABLE OF CONTENTS (03/2013) SOLICITATION PACKAGE - PAGE 9

A. GENERAL PROVISIONS

A.1. Definitions

As used herein, the following terms shall have the following meaning unless the context clearly indicates otherwise:

A.1.1. "Acquisition” means items, products, materials, supplies, services, and equipment a state agency acquires by purchase, lease purchase, lease with option to purchase, or rental pursuant to the Oklahoma Central Purchasing Act; A.1.2. ”Bid” means an offer in the form of a bid, proposal, or quote a bidder submits in response to a solicitation;

A.1.3. "Bidder" means an individual or business entity that submits a bid in response to a solicitation;

A.1.4. "Solicitation" means a request or invitation by the State Purchasing Director or a state agency for a supplier to submit a priced offer to sell acquisitions to the state. A solicitation may be an invitation to bid, request for proposal, or a request for quotation; and A.1.5. ”Supplier” or “vendor” means an individual or business entity that sells or desires to sell acquisitions to state agencies. A.2. Bid Submission

A.2.1. Submitted bids shall be in strict conformity with the instructions to bidders and shall be submitted with a completed Responding Bidder Information, OMES-FORM-CP-076, and any other forms required by the solicitation. A.2.2. Bids shall be submitted to the Central Purchasing Division in a single envelope, package, or container and shall be sealed, unless otherwise detailed in the solicitation. The name and address of the bidder shall be inserted in the upper left corner of the single envelope, package, or container. SOLICITATION NUMBER AND SOLICITATION RESPONSE DUE DATE AND TIME MUST APPEAR ON THE FACE OF THE SINGLE ENVELOPE, PACKAGE, OR CONTAINER. A.2.3. The required certification statement, "Certification for Competitive Bid and/or Contract (Non-Collusion Certification)", OMES-FORM-CP-004, must be made out in the name of the bidder and must be properly executed by an authorized person, with full knowledge and acceptance of all its provisions. A.2.4. All bids shall be legible and completed in ink or with electronic printer or other similar office equipment. Any corrections to bids shall be identified and initialed in ink by the bidder. Penciled bids and penciled corrections shall NOT be accepted and will be rejected as non-responsive. In addition to a hard copy submittal, the bidder will also be required to submit an electronic copy. Electronic responses must be submitted in the identical format contained in the solicitation (for example Microsoft Word, Microsoft Excel, but not Adobe PDF). In the event the hard copy of the price worksheets and electronic copy of the price worksheets do not agree, the electronic copy will prevail. A.2.5. All bids submitted shall be subject to the Oklahoma Central Purchasing Act, Central Purchasing Rules, and other statutory regulations as applicable, these General Provisions, any Special Provisions, solicitation specifications, required certification statement, and all other terms and conditions listed or attached herein—all of which are made part of this solicitation. A.3. Solicitation Amendments

A.3.1. If an ”Amendment of Solicitation”, OMES-FORM-CP-011, is issued, the bidder shall acknowledge receipt of any/all amendment(s) to solicitations by signing and returning the solicitation amendment(s). Amendment acknowledgement(s) may be submitted with the bid or may be forwarded separately. If forwarded separately, amendment acknowledgement(s) must contain the solicitation number and response due date and time on the front of the envelope. The Central Purchasing Division must receive the amendment acknowledgement(s) by the response due date and time specified for receipt of bids for the bid to be deemed responsive. Failure to acknowledge solicitation amendments may be grounds for rejection. A.3.2. No oral statement of any person shall modify or otherwise affect the terms, conditions, or specifications stated in the solicitation. All amendments to the solicitation shall be made in writing by the Central Purchasing Division. A.3.3. It is the Bidder's responsibility to check the OMES/Central Purchasing Division website frequently for any possible amendments that may be issued. The Central Purchasing Division is not responsible for a bidder's failure to download any amendment documents required to complete a solicitation.

OMES/PURCHASING – GENERAL PROVISIONS (04/11/2014) SOLICITATION PACKAGE PAGE 5

A.4. Bid Change

If the bidder needs to change a bid prior to the solicitation response due date, a new bid shall be submitted to the Central Purchasing Division with the following statement "This bid supersedes the bid previously submitted" in a single envelope, package, or container and shall be sealed, unless otherwise detailed in the solicitation. The name and address of the bidder shall be inserted in the upper left corner of the single envelope, package, or container. SOLICITATION NUMBER AND SOLICITATION RESPONSE DUE DATE AND TIME MUST APPEAR ON THE FACE OF THE SINGLE ENVELOPE, PACKAGE, OR CONTAINER. A.5. Certification Regarding Debarment, Suspension, and Other Responsibility Matters

By submitting a response to this solicitation:

A.5.1. The prospective primary participant and any subcontractor certifies to the best of their knowledge and belief, that they and their principals or participants: A.5.1.1. Are not presently debarred, suspended, proposed for debarment, declared ineligible, or voluntarily excluded by any Federal, State or local department or agency; A.5.1.2. Have not within a three-year period preceding this proposal been convicted of or pled guilty or had a civil judgment rendered against them for commission of fraud or a criminal offense in connection with obtaining, attempting to obtain, or performing a public (Federal, State or local) contract; or for violation of Federal or State antitrust statutes or commission of embezzlement, theft, forgery, bribery, falsification or destruction of records, making false statements, or receiving stolen property; A.5.1.3. Are not presently indicted for or otherwise criminally or civilly charged by a governmental entity (Federal, State, or local) with commission of any of the offenses enumerated in paragraph A.5.1.2. of this certification; and A.5.1.4. Have not within a three-year period preceding this application/proposal had one or more public (Federal, State, or local) contracts terminated for cause or default. A.5.2. Where the prospective primary participant is unable to certify to any of the statements in this certification, such prospective participant shall attach an explanation to its solicitation response. A.6. Bid Opening

Sealed bids shall be opened by the Central Purchasing Division at the Will Rogers Building, 2401 N. Lincoln Blvd. First Floor, Suite 116, Oklahoma City, Oklahoma, 73105 at the time and date specified in the solicitation as Response Due Date and Time. A.7. Open Bid / Open Record

Pursuant to the Oklahoma Public Open Records Act, a public bid opening does not make the bid(s) immediately accessible to the public. The procurement or contracting agency shall keep the bid(s) confidential, and provide prompt and reasonable access to the records only after a contract is awarded or the solicitation is cancelled. This practice protects the integrity of the competitive bid process and prevents excessive disruption to the procurement process. The interest of achieving the best value for the State of Oklahoma outweighs the interest of vendors immediately knowing the contents of competitor’s bids. [51 O.S. § 24A.5(5)] Additionally, financial or proprietary information submitted by a bidder may be designated by the Purchasing Director as confidential and the procurement entity may reject all requests to disclose information designated as confidential pursuant to 62 O.S. (2012) § 34.11.1(H)(2) and 74 O.S. (2011) § 85.10. Bidders claiming any portion of their bid as proprietary or confidential must specifically identify what documents or portions of documents they consider confidential and identify applicable law supporting their claim of confidentiality. The State Purchasing Director shall make the final decision as to whether the documentation or information is confidential pursuant to 74 O.S. § 85.10. Otherwise, documents and information a bidder submits as part of or in connection with a bid are public records and subject to disclosure after contract award or the solicitation is cancelled. A.8. Late Bids

Bids received by the Central Purchasing Division after the response due date and time shall be deemed non-responsive and shall NOT be considered for any resultant award. A.9. Legal Contract

A.9.1. Submitted bids are rendered as a legal offer and any bid, when accepted by the Central Purchasing Division, shall constitute a contract. A.9.2. The Contract resulting from this solicitation may consist of the following documents in order of preference: A.9.2.1. Purchase order, as amended by Change Order (if applicable); A.9.2.2. Solicitation, as amended (if applicable); and

OMES/PURCHASING – GENERAL PROVISIONS (04/11/2014) SOLICITATION PACKAGE PAGE 6

A.9.2.3. Successful bid (including required certifications), to the extent the bid does not conflict with the requirements of the solicitation or applicable law. A.9.3. Any contract(s) awarded pursuant to the solicitation shall be legibly written or typed. A.10. Pricing

A.10.1. Bids shall remain firm for a minimum of sixty (60) days from the solicitation closing date. A.10.2. Bidders guarantee unit prices to be correct. A.10.3. In accordance with 74 O.S. §85.40, ALL travel expenses to be incurred by the supplier in performance of the Contract shall be included in the total bid price/contract amount. A.11. Manufacturers' Name and Approved Equivalents

Unless otherwise specified in the solicitation, manufacturers' names, brand names, information and/or catalog numbers listed in a specification are for information and not intended to limit competition. Bidder may offer any brand for which they are an authorized representative, and which meets or exceeds the specification for any item(s). However, if bids are based on equivalent products, indicate on the bid form the manufacturer's name and number. Bidder shall submit sketches, descriptive literature, and/or complete specifications with their bid. Reference to literature submitted with a previous bid will not satisfy this provision. The bidder shall also explain in detail the reason(s) why the proposed equivalent will meet the specifications and not be considered an exception thereto. Bids that do not comply with these requirements are subject to rejection. A.12. Clarification of Solicitation

A.12.1. Clarification pertaining to the contents of this solicitation shall be directed in writing to the Central Purchasing Contracting Officer specified in the solicitation, and must be prior to the closing date of the solicitation. A.12.2. If a bidder fails to notify the State of an error, ambiguity, conflict, discrepancy, omission or other error in the SOLICITATION, known to the bidder, or that reasonably should have been known by the bidder, the bidder shall submit a bid at its own risk; and if awarded the contract, the bidder shall not be entitled to additional compensation, relief, or time, by reason of the error or its later correction. If a bidder takes exception to any requirement or specification contained in the SOLICITATION, these exceptions must be clearly and prominently stated in their response. A.12.3. Bidders who believe proposal requirements or specifications are unnecessarily restrictive or limit competition may submit a written request for administrative review to the contracting officer listed on the solicitation. This request must be made prior to the closing date of the solicitation. A.13 Negotiations A.13.1. In accordance with Title 74 §85.5, the State of Oklahoma reserves the right to negotiate with one, selected, all or none of the vendors responding to this solicitation to obtain the best value for the State. Negotiations could entail discussions on products, services, pricing, contract terminology or any other issue that may mitigate the State’s risks. The State shall consider all issues negotiable and not artificially constrained by internal corporate policies. Negotiation may be with one or more vendors, for any and all items in the vendor’s offer. A.13.2. Firms that contend that they lack flexibility because of their corporate policy on a particular negotiation item shall face a significant disadvantage and may not be considered. If such negotiations are conducted, the following conditions shall apply: A.13.3. Negotiations may be conducted in person, in writing, or by telephone. A.13.4. Negotiations shall only be conducted with potentially acceptable offers. The State reserves the right to limit negotiations to those offers that received the highest rankings during the initial evaluation phase. A.13.5. Terms, conditions, prices, methodology, or other features of the offeror’s offer may be subject to negotiations and subsequent revision. As part of the negotiations, the offeror may be required to submit supporting financial, pricing, and other data in order to allow a detailed evaluation of the feasibility, reasonableness, and acceptability of the offer. A.13.6. The requirements of the Request for Proposal shall not be negotiable and shall remain unchanged unless the State determines that a change in such requirements is in the best interest of the State Of Oklahoma. A.14. Rejection of Bid The State reserves the right to reject any bids that do not comply with the requirements and specifications of the solicitation. A bid may be rejected when the bidder imposes terms or conditions that would modify requirements of the solicitation or limit the bidder's liability to the State. Other possible reasons for rejection of bids are listed in OAC 580:16-7-32.

OMES/PURCHASING – GENERAL PROVISIONS (04/11/2014) SOLICITATION PACKAGE PAGE 7

A.15. Award of Contract

A.15.1. The State Purchasing Director may award the Contract to more than one bidder by awarding the Contract(s) by item or groups of items, or may award the Contract on an ALL OR NONE basis, whichever is deemed by the State Purchasing Director to be in the best interest of the State of Oklahoma. A.15.2. Contract awards will be made to the lowest and best bidder(s) unless the solicitation specifies that best value criteria is being used. A.15.3. In order to receive an award or payments from the State of Oklahoma, suppliers must be registered. The vendor registration process can be completed electronically through the OMES website at the following link: https://www.ok.gov/dcs/vendors/index.php . A.16. Contract Modification

A.16.1. The Contract is issued under the authority of the State Purchasing Director who signs the Contract. The Contract may be modified only through a written Contract Modification, signed by the State Purchasing Director. A.16.2. Any change to the Contract, including but not limited to the addition of work or materials, the revision of payment terms, or the substitution of work or materials, directed by a person who is not specifically authorized by the Central Purchasing Division in writing, or made unilaterally by the supplier, is a breach of the Contract. Unless otherwise specified by applicable law or rules, such changes, including unauthorized written Contract Modifications, shall be void and without effect, and the supplier shall not be entitled to any claim under this Contract based on those changes. No oral statement of any person shall modify or otherwise affect the terms, conditions, or specifications stated in the resultant Contract. A.17. Delivery, Inspection and Acceptance

A.17.1. Unless otherwise specified in the solicitation or awarding documents, all deliveries shall be F.O.B. Destination. The bidder(s) awarded the Contract shall prepay all packaging, handling, shipping and delivery charges and firm prices quoted in the bid shall include all such charges. All products and/or services to be delivered pursuant to the Contract shall be subject to final inspection and acceptance by the State at destination. "Destination” shall mean delivered to the receiving dock or other point specified in the purchase order. The State assumes no responsibility for goods until accepted by the State at the receiving point in good condition. Title and risk of loss or damage to all items shall be the responsibility of the supplier until accepted by the receiving agency. The supplier(s) awarded the Contract shall be responsible for filing, processing, and collecting any and all damage claims accruing prior to acceptance. A.17.2. Supplier(s) awarded the Contract shall be required to deliver products and services as bid on or before the required date. Deviations, substitutions or changes in products and services shall not be made unless expressly authorized in writing by the Central Purchasing Division. A.18. Invoicing and Payment

A.18.1. Pursuant to 74 O.S. §85.44(B), invoices will be paid in arrears after products have been delivered or services provided. A.18.2. Interest on late payments made by the State of Oklahoma is governed by 62 O.S. §34.71 and 62 O.S. §34.72. A.19. Tax Exemption

State agency acquisitions are exempt from sales taxes and federal excise taxes. Bidders shall not include these taxes in price quotes. A.20. Audit and Records Clause

A.20.1. As used in this clause, “records" includes books, documents, accounting procedures and practices, and other data, regardless of type and regardless of whether such items are in written form, in the form of computer data, or in any other form. In accepting any Contract with the State, the successful bidder(s) agree any pertinent State or Federal agency will have the right to examine and audit all records relevant to execution and performance of the resultant Contract. A.20.2. The successful bidder(s) awarded the Contract(s) is required to retain records relative to the Contract for the duration of the Contract and for a period of seven (7) years following completion and/or termination of the Contract. If an audit, litigation, or other action involving such records is started before the end of the seven (7) year period, the records are required to be maintained for two (2) years from the date that all issues arising out of the action are resolved, or until the end of the seven (7) year retention period, whichever is later. A.21. Non-Appropriation Clause

The terms of any Contract resulting from the solicitation and any Purchase Order issued for multiple years under the Contract are contingent upon sufficient appropriations being made by the Legislature or other appropriate government entity. Notwithstanding any

OMES/PURCHASING – GENERAL PROVISIONS (04/11/2014) SOLICITATION PACKAGE PAGE 8 language to the contrary in the solicitation, purchase order, or any other Contract document, the procuring agency may terminate its obligations under the Contract if sufficient appropriations are not made by the Legislature or other appropriate governing entity to pay amounts due for multiple year agreements. The Requesting (procuring) Agency's decisions as to whether sufficient appropriations are available shall be accepted by the supplier and shall be final and binding. A.22. Choice of Law Any claims, disputes, or litigation relating to the solicitation, or the execution, interpretation, performance, or enforcement of the Contract shall be governed by the laws of the State of Oklahoma.

A.23. Choice of Venue Venue for any action, claim, dispute or litigation relating in any way to the Contract shall be in Oklahoma County, Oklahoma.

A.24. Termination for Cause

A.24.1. The supplier may terminate the Contract for default or other just cause with a 30-day written request and upon written approval from the Central Purchasing Division. The State may terminate the Contract for default or any other just cause upon a 30-day written notification to the supplier. A.24.2. The State may terminate the Contract immediately, without a 30-day written notice to the supplier, when violations are found to be an impediment to the function of an agency and detrimental to its cause, when conditions preclude the 30-day notice, or when the State Purchasing Director determines that an administrative error occurred prior to Contract performance. A.24.3. If the Contract is terminated, the State shall be liable only for payment for products and/or services delivered and accepted.

A.25. Termination for Convenience

A.25.1. The State may terminate the Contract, in whole or in part, for convenience if the State Purchasing Director determines that termination is in the State's best interest. The State Purchasing Director shall terminate the Contract by delivering to the supplier a Notice of Termination for Convenience specifying the terms and effective date of Contract termination. The Contract termination date shall be a minimum of 60 days from the date the Notice of Termination for Convenience is issued by the State Purchasing Director. A.25.2. If the Contract is terminated, the State shall be liable only for products and/or services delivered and accepted, and for costs and expenses (exclusive of profit) reasonably incurred prior to the date upon which the Notice of Termination for Convenience was received by the supplier. A.26. Insurance The successful bidder(s) awarded the Contract shall obtain and retain insurance, including workers' compensation, automobile insurance, medical malpractice, and general liability, as applicable, or as required by State or Federal law, prior to commencement of any work in connection with the Contract. The supplier awarded the Contract shall timely renew the policies to be carried pursuant to this section throughout the term of the Contract and shall provide the Central Purchasing Division and the procuring agency with evidence of such insurance and renewals.

A.27. Employment Relationship The Contract does not create an employment relationship. Individuals performing services required by this Contract are not employees of the State of Oklahoma or the procuring agency. The supplier's employees shall not be considered employees of the State of Oklahoma nor of the procuring agency for any purpose, and accordingly shall not be eligible for rights or benefits accruing to state employees.

A.28. Compliance with the Oklahoma Taxpayer and Citizen Protection Act of 2007 By submitting a bid for services, the bidder certifies that they, and any proposed subcontractors, are in compliance with 25 O.S. §1313 and participate in the Status Verification System. The Status Verification System is defined in 25 O.S. §1312 and includes but is not limited to the free Employment Verification Program (E-Verify) through the Department of Homeland Security and available at www.dhs.gov/E-Verify .

A.29. Compliance with Applicable Laws The products and services supplied under the Contract shall comply with all applicable Federal, State, and local laws, and the supplier shall maintain all applicable licenses and permit requirements.

A.30. Special Provisions Special Provisions set forth in SECTION B apply with the same force and effect as these General Provisions. However, conflicts or inconsistencies shall be resolved in favor of the Special Provisions.

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B. SPECIAL PROVISIONS B.1. Contract Period B.1.1. This contract will be in effect from Date of Award through June 30, 2015 with the option to renew for four additional one year periods beginning July 1st and ending June 30th of each year until June 30, 2019 at the same terms and conditions. B.1.2. Renewal will be dependent upon the availability of funding, ODMHSAS need, and meeting RFP requirements. Services may not be provided until the Central Purchasing Division has issued a purchase order. B.2. Extension of Contract B.2.1. The State may extend the term of this contract for up to 90 day intervals if mutually agreed upon by both parties in writing. B.3. Definitions B.3.1. ODMHSAS: Oklahoma Department of Mental Health and Substance Abuse Services. B.3.2. Department: As used in this Request for Proposals, Department means the Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS). B.4. Access to Records B.4.1. This clause is in addition to A.19, Audit and Records Clause. The Contractor agrees that books, records, documents, accounting procedures, practices or any other items of the service provider relevant to this Contract are subject to inspection, examination and copying by the Department, its designee, and the Office of the Oklahoma State Auditor and Inspector. Further, the Contractor shall fully cooperate with the Department during investigations of complaints involving patient abuse, neglect, improper treatment or any violation of patient rights. Cooperation shall include, but is not limited to, immediate access to clients, staff members, facilities, client records, or any other records or documents regularly kept by the Contractor. Contractor shall retain required records and supporting documentation for validation of costs billed for seven (7) years from the ending date of the contract. B.5. Advance Payments Prohibited B.5.1. ODMHSAS shall not make payments in advance of or in anticipation of goods or services. B.6. Affirmation B.6.1. Contractor, by execution of this Contract, acknowledges and affirms that he/she (1) is not a current employee of any agency of the State of Oklahoma and (2) has not been an employee of any agency of the State of Oklahoma within the twelve (12) months next preceding the effective date of this Contract. B.7. Amendments/Contract Modifications B.7.1. Any amendments/contract modifications to this contract shall be in writing, dated and executed by both the Contractor and ODMHSAS. Once the document has been signed/approved by the Contractor and ODMHSAS please refer to A.15 Contract Modification for the remaining procedure. B.8. Assignment and Delegation B.8.1. The service to be performed under this contract shall not be subcontracted, in whole or in part, to any other person or entity without the prior written consent of ODMHSAS. If the Contractor cannot perform the services as identified in this contract, the Contractor will be responsible for subcontracting the services or making alternative arrangements for the provisions of the services. The terms of this contract shall be included in any subcontract. The Contractor will be liable for all additional costs and expenses arising from such subcontract or substitution to cover performance. Approval of any subcontract shall not relieve the Contractor of any responsibility for performance under this contract. B.9. Audit-Type Certification B.9.1. With the type-of-audit certification, the Contractor shall identify the type of audit the Contractor intends to obtain for the period covered by this contract. The completed form shall be submitted with a signed copy of this contract to the Department’s Contract Management Division. As needed, the contractor shall use the form to notify the Department of a change in the type of audit previously certified when circumstances show that the initial certification is no longer correct. B.10. Budget Revisions B.10.1. A budget revision request submitted by the Contractor during the contract period must include a revised Attachment as well as a narrative explanation of the reasons for the revision request and the benefit to the program resulting from the revision. To allow for flexibility in dealing with programmatic changes, staff

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turnover, and other unexpected administrative issues, budget revisions may be submitted with approval from the ODMHSAS within 30 days of the anticipated change. B.10.2. Budget revisions may not change the scope of work of the contract. A scope change occurs when a budget is revised in such a way that it does not provide for the expenditures necessary to fulfill the Contractor’s duties and performance requirements as stated in the entire agreement. Budget revisions must be requested in advance of incurring expenditures and are not effective until approved in writing by the ODMHSAS. Expenditures incurred without prior approval of a budget revision shall be the responsibility of the Contractor and will not be reimbursed by ODMHSAS B.11. Cancellation Clause B.11.1. This contract shall be in force until the expiration date or until 30 days after notice has been given by either party of its desire to cancel. Please refer to A.23 Termination for Cause. ODMHSAS shall send a notification of cancellation by certified mail to the business address of record. B.12. Contract Compliance B.12.1. This clause is in addition to A.23 Termination and A.24 Termination for Convenience. B.12.2. The Department may terminate the Contract in the event of a material default by Contractor, provided that the Department shall provide written notice to Contractor specifying the default in reasonable detail. Contractor shall have thirty (30) days in which to cure its default, except in the instance of health and safety issues, in which case termination may be immediate. If Contractor fails to cure such default within the relevant cure period, the Department may terminate the Contract and this Operating Agreement by giving written notice to Contractor, specifying the effective date of the termination. B.12.3. The Contract may be terminated by the Department immediately and without prior notice if the Department reasonably determines that the health or safety of the persons served is in imminent jeopardy due to the actions or inactions of Contractor or those under Contractor’s control. B.12.4. A default in performance by Contractor for which the Contract may be terminated shall include: failure or refusal to perform, observe and comply with any covenant or agreement according to its terms, conditions and specifications, failure to maintain the care and treatment services in accordance with the Department’s rules and regulations and default in payment of state taxes. B.12.5. Termination shall not be the exclusive remedy available to the Department for a default by the Contractor, but shall be in addition to any other rights and remedies provided for by law or equity. B.12.6. The Department shall not be liable for any further payment to Contractor under a contract terminated for the Contractor’s defaults after the date of such default as determined by the Department, except for commodities, supplies, equipment or services delivered and accepted on or before the date of default and for which payment had not been made as of that date. Contractor shall be liable to, and shall indemnify and hold harmless, the Department for all liability, cost or damage sustained by the Department as a result of Contractor’s default. In the event of a tax lien filed against Contractor, the Department cannot make any payments to Contractor until such tax lien is satisfied. B.13. Monitoring B.13.1. The Department will monitor the Contractors performance of this contract. Contractor shall cooperate with the Department in its monitoring activities and shall comply with Department requests that facilitate such monitoring. B.14. Contractor’s Relation to ODMHSAS B.14.1. The Contractor is in all respects an independent Contractor and is neither an agent nor an employee of ODMHSAS. Neither the Contractor nor any of its officers, employees, agents, or members shall have authority to bind ODMHSAS, nor are they entitled to any of the benefits or worker’s compensation provided by ODMHSAS to its employees. Please refer to A.26. B.15. Drug-Free Workplace B.15.1. The Contractor certifies it will or will continue to provide a drug free workplace in accordance with the Drug Free Workplace Act of 1988 and implemented at 45 CFR Part 76, Subpart F for grantees, as defined at 45 CFR Part 76, Sections 76.605 and 76.610. B.16. Invoicing B.16.1. A properly completed invoice must be submitted within 60 days of the end of the month in which services were delivered and include the following items: B.16.1.1. Name and address of the Contractor. B.16.1.2. Invoice date.

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B.16.1.3. Period covered by the invoice. B.16.1.4. Purchase order number. B.16.1.5. Amount B.16.1.6. Any other data, reports, information, or documentation required by other conditions of the contract, including copies of receipts for supplies, trainings, travel, other, etc. that are being claimed for reimbursement. B.16.1.6.1. NOTE: If travel costs and related expenses are a part of the contract, they shall not exceed those authorized by the State Travel Reimbursement Act, Title 74.0 S. 2001 §500.1 et seq. All out-of-state travel where reimbursement is requested must be pre-approved in writing by ODMHSAS. Funds will be paid on a REIMBURSEMENT BASIS FOR ACTUAL EXPSENSE. B.16.2. The invoice shall be submitted to: B.16.2.1. OKLAHOMA DEPARTMENT OF MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES B.16.2.2. Attn: Krystal Beltran B.16.2.3. 1200 NE 13th Street B.16.2.4. Oklahoma City, Oklahoma 73152-3277 B.16.3. The State of Oklahoma has 45 days from presentation of a proper invoice to issue payment to the contractor. B.16.4. ODMHSAS may withhold or delay payment to any Contractor failing to provide required programmatic documentation and/or requested financial documentation. B.16.5. If the Contractor is unable to support any part of its claim to ODMHSAS and it is determined that such inability is attributed to misrepresentation of fact or fraud on the part of the Contractor, the Contractor shall be liable to ODMHSAS for an amount equal to such unsupported part of the claim in addition to all costs, including legal, attributable to the reviewing and discovery of said part of claim. Liability under this section shall be determined within five years of the commission of such misrepresentation of fact or fraud. B.16.6. ODMHSAS may routinely request supporting documentation to validate vendor payments. B.17. Equipment and Other Purchases B.17.1.1. It is understood that no items of equipment, property, or other capital purchases shall be reimbursed under the provisions of this contract. B.18. Event of Default B.18.1. This clause is in addition to A.23 Termination for Cause. In the event the Contractor fails to meet the terms and conditions of this contract or to provide services in accordance with the provisions of the contract, the State of Oklahoma at its sole discretion may withhold payments claimed by the Contractor or may cancel this contract by written notice of default to the Contractor. Cancellation due to default shall not be an exclusive remedy but shall be in addition to any other rights and remedies provided for by law. B.19. Failure to Comply Statement B.19.1. The Contractor shall be subject to all applicable state and federal laws, rules and regulations, and all amendments thereto. The Contractor agrees that should it be in noncompliance the contract may be suspended or canceled in part or in whole. Compliance with the requirements shall be the responsibility of the Contractor, without reliance on or direction by ODMHSAS. B.20. Financial Audit B.20.1. A financial statement audit or other engagement is required under the conditions provided below. The type of audit or engagement is determined separately for state and federal funds. State funds include only those received from the Department. Federal funds include those from all sources (federal agencies, the Department, or other entities). The expenditure of federal funds is based on when the activity for the expenditure occurs, not when the expenditure is made. The Department will notify the Contractor of any federal awards made under this contract. Non-fee for service awards must be accounted for separately from all other funds and awards. The Department reserves the right to require an independent financial statement audit of the Contractor, the cost of which shall be paid by the Contractor. B.20.2. State funds. A state or local governmental entity shall obtain a financial statement audit conducted in accordance with generally accepted governmental auditing standards (Yellow Book). For awards of $100,000 or more, a nongovernmental contractor shall obtain an audit conducted in accordance with generally accepted auditing standards (basic type).

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B.20.3. Federal funds (expenditures of $500,000 or more from all sources). The Contractor shall obtain an audit conducted in accordance with the Single Audit Act of 1984, as revised by the Single Audit Act Amendments of 1996, and OMB Circular A 133. An applicable portion of federal funds (such as the percentage of federal fund expenditures to total expenditures) may be used to pay for this audit when the audit covers all funds and operations of the Contractor. In addition to obtaining a Single Audit, the Contractor shall permit the Department to perform a compliance engagement or have a compliance engagement performed of the Department’s federal award(s). Such engagement, if conducted, shall be at the Department’s expense. B.20.4. Federal funds (expenditures of less than $500,000 from all sources). Federal compliance monitoring shall be performed either currently or within the next two years. This monitoring will be done at the direction of the Department for funds received from the Department. B.20.5. Regardless of the above provisions, the Contractor shall submit to the Department a copy of financial audit reports obtained for other reasons. This copy shall include, if present, the additional Yellow Book reports, the additional A-133 reports, and the management letter. B.20.6. Audits under this section shall be performed by independent and properly licensed Certified Public Accountants or Public Accountants. For the audit of federal funds, a Public Accountant shall have been properly licensed on or before December 31, 1970, or shall work for a properly licensed firm (licensed on or before December 31, 1970, if a Public Accountant firm). B.20.7. Unless otherwise provided, a financial statement audit shall include, in one or more reports, all operations and funds of the Contractor and of any entities or persons related to or affiliated with the Contractor. The audited financial statements of nongovernment entities shall include at least a statement of financial position, a statement of activities, a statement of cash flows, and a statement of functional expenses. If state funds are received under this contract, the audited financial statement report shall also include a supplementary schedule of state awards, which identifies each award, the amount awarded and the total amount received or recognized. B.20.8. The audit(s) shall be for the Contractor's fiscal year(s) during which this contract is in force. B.20.9. The Contractor shall submit one complete copy of its financial statement audit report(s), as required above, to the Department’s Internal Audit Division within six (6) months of the close of the Contractor's fiscal year(s). The copy shall include, as applicable, copies of all reports issued pursuant to Office of Management and Budget Circular A-133 and Government Auditing Standards. A management letter, if issued, shall be submitted. B.20.10. The books and records of the Contractor and the work papers of the Contractor’s auditor shall be made available, if needed, to the Department’s cognizant federal agency, the Department, the Department’s auditor, the State Auditor and Inspector, and the Comptroller General of the United States. B.20.11. The due date of a report may be extended for good cause. For an extension to be considered, a request for such must be submitted in writing to the Department’s Internal Audit Division on or before the applicable due date. B.20.12. Contractor agrees to promptly notify the Department of any change in the. B.20.13. Compliance with the audit provisions of this contract is not considered achieved until the Department has reviewed and accepted the report(s). Failure by the Contractor to timely submit a required report may, upon reasonable notice; result in withholding by the Department of payments otherwise due under the terms of this contract. B.21. Confidentiality B.21.1. The Bidder agrees to the following and: B.21.1.1. Acknowledges that in receiving, transmitting, transporting, storing, processing, or otherwise dealing with any information received from ODMHSAS or from providing services to ODMHSAS, identifying or otherwise relating to the clients or participants of ODMHSAS (hereinafter “protected information”), it is fully bound by the provisions of the federal regulations governing the confidentiality of Alcohol and Drug Abuse Patient Records, 42 C.F.R. Part 2 and the HIPAA, 45 C.F.R. 45 Parts 142, 160, and 164 to include the HITECH section of American Recovery and Reinvestment Act (ARRA), and the Title 43 A § 1-109 of Oklahoma Statutes and may not use or disclose the information except as permitted or required by this Agreement or by law; B.21.1.2. Acknowledges that pursuant to 43A O.S. §1-109, all mental health and drug or alcohol treatment information and all communications between physician or psychotherapist and patient are both privileged and confidential and that such information is available only to persons actively engaged in treatment of the client or participant or in related administrative work, which includes evaluation; B.21.1.3.

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B.21.1.4. B.21.1.5. Agrees to resist any efforts in judicial proceedings to obtain access to the protected information except as expressly provided for in the regulations governing the Confidentiality of Alcohol and Drug Abuse patient Records, 42 C.F.R Part 2; B.21.1.6. Agrees to use appropriate administrative, physical, and technical safeguards that reasonably and appropriately protect the confidentiality, integrity, and availability of the electronic protected health information that it creates receives, maintains, or transmits on behalf of ODMHSAS and to use appropriate safeguards to prevent the unauthorized use or disclosure of the protected information; B.21.1.7. Agrees to report to ODMHSAS any use or disclosure or any security incident involving protected information not provided for by this Agreement within twenty-four (24) hours of which it becomes aware; B.21.1.8. Agrees to provide access to the protected information at the request of ODMHSAS, or to an individual as directed by ODMHSAS, in order to meet the requirement of 45 C.F.R. §164.524 which provides clients with the right to access and copy their own protected information; B.21.1.9. Agrees to make any amendments to the protected information as directed or agreed to by ODMHSAS pursuant to 45 C.F.R. §164.526; B.21.1.10. Agrees to make available its internal practices, books, and records, including policies and procedures, relating to the use and disclosure of protected information received from ODMHSAS or created or received by the Bidder on behalf of ODMHSAS, to ODMHSAS and to the Secretary of the Department of Health and Human Services for purposes of the Secretary determining ODMHSAS’ compliance with HIPAA; B.21.1.11. Agrees to provide ODMHSAS, or an individual, information to permit ODMHSAS to respond to a request by an individual for an accounting of disclosures in accordance with 45 C.F.R. §164.528; B.21.1.12. If Bidder uses an in-house management information system to batch load data to Department’s designated site, Bidder must assure the system can provide HIPAA compliant transactions. Department currently collects certain participant information electronically in addition to the HIPAA required data transactions. These data will continue to be required. All in- house management information systems must be able to provide all ODMHSAS required participant data or the data must be entered via the Department approved online system. B.21.1.13. Any violation of the terms of this section including the unauthorized use of the MMIS secure website or information on the secure website may result in suspension or termination of Bidder’s access to the MMIS secure website and the secure websites. B.22. Indemnification B.22.1. This clause is in addition to A.25 Insurance. The Bidder shall at all times carry and Commercial General liability insurance of no less than one million dollars ($1,000,000) for any aggregate claim per incident. For professional services Bidders, they must also provide Professional Liability insurance to adequately compensate persons for an act of professional negligence by the Bidder, its agents, employees or the like. Said policies must provide that the carrier may not cancel or transfer the policy without giving the Department thirty (30) days written notice prior to the cancellation or transfer. The Bidder shall timely renew the policies to be carried pursuant to this section throughout the term of the contract and provide the Department with evidence of such insurance and renewals upon request. B.22.2. Bidder shall indemnify and hold harmless ODMHSAS against any and all bodily injury and property damage, deficiencies or liabilities resulting from any negligence on the part of Bidder, its employees or independent Bidders, or non-fulfillment of any term or condition of this contract. Bidder shall indemnify and hold harmless the Department under the contract from any and all assessments, judgments, costs, legal, and other reasonable expenses incidental to any of the forgoing. B.23. Influence B.23.1. As required by Section 1352, Title 31 of the U.S. Code, and implemented at 45 CFR Part 93, for persons entering into a grant or cooperative agreement over $100,000, as defined at 45 CFR Part 93, Section 93.105 and 93.110, the applicant/provider certifies that: B.23.1.1. No Federal appropriated funds have been paid or will be paid by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or employee of any agency, a Member of Congress, an officer or employee of Congress or any employee of a Member of Congress in connection with the making of any Federal grant, the entering into of any cooperative agreement and the extension, continuation, renewal, amendment or modification of any Federal grant or cooperative agreement.

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B.24. Immediate Cancellation B.24.1. Immediate cancellation will be administered when violations are found to be an impediment to the function of the agency and detrimental to its cause, or when conditions preclude the 30 day notice. B.25. No Grant of Authority B.25.1. Nothing herein shall be construed as conferring upon Contractor the authority to assume or incur any liability or any obligation of any kind, expressed or implied, in the name of or on behalf of the Department, and Contractor agrees not to assume or incur any such liability or obligation without the prior expressed written consent of the Department. B.26. No Other Agreement B.26.1. Contractor certifies and warrants that it has entered into no other agreement that would prevent performance of the services agreed to herein on the terms and conditions stated. Contractor further certifies and warrants that no such agreement will be entered into during the pendency of this Contract. B.27. Non-Discrimination B.27.1. The Contractor is an Equal Opportunity Employer, a provider of services and/or assistance, and assures compliance with the 1964 Civil Rights Act, Title IX of the Education Amendments of 1972, Section 504 of the Rehabilitation Act of 1973, as amended, Executive Orders 11246 and 11375, and the Americans with Disabilities Act of 1990 (Public Law 101 336), all amendments to, and all requirements imposed by the regulations issued pursuant to this act. B.28. Notices B.28.1. Any notices to be given hereunder are deemed to be given when deposited with the United States Postal Service, certified or registered mail, return receipt requested, with sufficient postage prepaid, addressed as indicated herein. Either party may at any time designate any other address by giving written notice to the other party. B.29. Other Certifications B.29.1. The Contractor certifies compliance with the provisions of Titles VI and VII of the 1964 Civil Rights Act and Section 504 of the Rehabilitation Act 1973, the Age Discrimination Act of 1975, the Hatch Act, the Pro Children Act of 1994, Drug Free Workplace Act of 1988, the American with Disabilities Act of 1990, Title IX or the Education Amendments of 1972, 31 U.S.C. Sections 1352, Public Law 105-78, and the Single Audit Act of 1984, as applicable. B.30. Open Meeting Law B.30.1. Contractor shall comply with the provisions of the state’s Open Meeting Law. B.31. Performance Suspension B.31.1. Performance may be suspended by either party for any Act of God, war, riots, fire, explosion, strike, injunction, inability to obtain fuel, power, labor, or transportation, accident, national defense requirements, or any cause beyond the control of such party, which prevents the performance of such party. An alleged breach of this contract by either party shall be grounds for immediate suspension of performance. B.32. Procurement Integrity B.32.1. The Contractor certifies it has not entered into this contract with this or any other state agency that would result in a substantial duplication of the services or duplication of the end product rendered by the Contractor or its employees. B.33. Promotional or Incentive Items B.33.1. Acquisitions of promotional or incentive items will comply with the established guidelines and limits established by ODMHSAS. Bidder shall submit written justification to the ODMHSAS and obtain prior approval on all promotional/incentive items prior to purchase. B.34. Recognition of Department Support B.34.1. Contractor shall state it is funded by the Oklahoma Department of Mental Health and Substance Abuse Services in all applicable promotional information (including but not limited to promotional or informational brochures, flyers, newsletters, posters, web sites, multi-media presentations, media releases, and community education presentations) regarding services funded by the Department. B.35. Reports B.35.1. The Department may prescribe and require reports from the Contractor during the effective dates of this Contract. All reports, financial and otherwise, required by the Department, shall be in the format as indicated by the Department and may include, but not be limited to, cost reports, expenditure reports, and

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balance sheets. The Department may, upon reasonable notice, withhold payments otherwise due under the terms of this contract, if the Contractor fails to submit required reports on a timely basis. B.36. Severability B.36.1. If any clause or provision of this contract is illegal, invalid or unenforceable under any present or future law, the remainder of this contract will not be affected thereby. It is the intention of the parties that if any provision is held to be illegal, invalid or unenforceable, there will be added in lieu thereof a provision as similar in terms to such provision as is possible to be legal, valid and enforceable. B.37. Specialized Services B.37.1. Contractors shall have policies and procedures for the provision of interpreters for persons who are deaf or hard of hearing or who speak a language other than English. B.38. Surveys B.38.1. The Contractor, upon reasonable notice, agrees to participate and cooperate in surveys, studies or research projects conducted by any governmental agency. B.39. Technical Assistance B.39.1. The Department, upon written request and if available, may provide to the Contractor technical assistance to ensure compliance with this contract. B.40. Tobacco B.40.1. The Bidder will implement or will continue to provide a tobacco-free campus in accordance with the standards of the Tobacco-Free Workplace policy of the Oklahoma Department of Mental Health and Substance Abuse Services, ODMHSAS 6.12. Possession and use of any tobacco product including cigarettes, electronic cigarettes, cigars, cigarillos, blunts, little cigars, roll your own, shisah tobacco (hookahs), dissolvable tobacco (orbs, sticks, strips), snus, cream or dry snuff, dokha, gutka, bidis, kreteks, topical tobacco paste, tobacco gel, tobacco water, tobacco gum (not to be confused with nicotine gum for cessation purposes), and any other product containing tobacco is prohibited on the grounds of and within ODMHSAS-operated and contracted facilities by employees, participants, volunteers, and visitors. B.40.2. All events supported by ODMHSAS contracts should be tobacco free. Events include trainings, special event fundraisers and awareness events, and comparable activity. Bidders should make an effort to communicate the tobacco free event status in signage and other communications surrounding the event. Bidders are also prohibited from accepting financial support from the manufacturers or distributors of tobacco products, their affiliates, or any entity controlling or controlled by such companies. B.41. Unavailability of Funding B.41.1. This clause is in addition to A.20 Non-Appropriation Clause. ODMHSAS may reduce the payment to the Contractor in the event a shortfall of state or federal funding occurs by written notice to the Contractor; except that the reduction will not affect payment for work completed prior to notice of the reduction in consideration. The amount decreased from the Contractor's payment shall be at the sole discretion of ODMHSAS and shall not be actionable by the Contractor; however, in the event of a contractual funding decrease, the Contractor reserves the right to negotiate the Statement of Work or terminate the Contract upon thirty (30) days written notice to the other party, or in accordance with the provisions set forth herein. B.42. Understanding of Terms B.42.1. The parties hereto have read and fully understand the terms of this contract and agree to be bound by same. B.43. Waiver of Breach B.43.1. No failure by the ODMHSAS to enforce any provisions hereof after any event of default by the Contractor shall be deemed a waiver of the ODMHSAS’s rights with regard to that event, or any subsequent event. Waiver shall not be construed to be a modification of the terms of the contract. B.44. Worker’s Compensation and Employer’s Liability B.44.1. The Contractor is required to comply with applicable federal and state worker’s compensation and occupational disease statutes. If occupational diseases are not covered under those statutes, they shall be covered under the employer’s section of the insurance policy. B.44.2. THE CONTRACTOR SHALL PROVIDE EVIDENCE OF INSURABILITY (CERTIFICATE OF INSURANCE), INCLUDING WORKER’S COMPENSATION, AUTOMOBILE INSURANCE, MEDICAL MALPRACTICE OR GENERAL LIABILITY, AS APPLICABLE, FROM THE INSURANCE CARRIER BEFORE THE COMMENCEMENT OF ANY WORK. SUCH POLICY OR POLICIES SHALL REQUIRE THIRTY (30) DAYS ADVANCE NOTICE OF CANCELLATION BE PROVIDED TO THE ODMHSAS PROCUREMENT DIVISION.

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B.45. BREACH OF CONTRACT B.45.1. Failure to perform any and all of the terms and conditions of this contract shall be deemed a substantial breach thereof and give the STATE cause to cancel this contract on seven (7) days written notice to the CONTRACTOR. The STATE then reserves the right to re-award the contract to the next lowest responsible available bidder -OR- should this contract be awarded to multiple vendors, the STATE may utilize those vendors. In the event of cancellation of this contract, the CONTRACTOR shall not be entitled to damages and agrees not to sue the STATE for damages thereof. After notice of cancellation, the CONTRACTOR agrees to perform the terms and conditions of this contract up to and including date of cancellation, as though no cancellation had been made and notwithstanding other legal remedies which may be available to the STATE because of the cancellation, agrees to indemnify the STATE for its costs in procuring the services of a new CONTRACTOR. B.46. Minor Deficiencies or Informalities B.46.1. "Minor deficiency" or "minor informality" means an immaterial defect in a bid or variation in a bid from the exact requirements of a solicitation that may be corrected or waived without prejudice to other bidders. A minor deficiency or informality does not affect the price, quantity, quality, delivery or conformance to specifications and is negligible in comparison to the total cost or scope of the acquisition. B.46.2. The State Purchasing Director may waive minor deficiencies or informalities in a bid if the State Purchasing Director determines the deficiencies or informalities do not prejudice the rights of other bidders, or are not a cause for bid rejection. B.47. Disclosures Regarding Lobbyist B.47.1. A vendor may not reimburse itself within its state contract pricing for its costs and expenses of lobbyists. B.47.2. Any vendor using the services of a lobbyist to assist in obtaining a contract shall B.47.2.1. Disclose all costs, fees, compensation, reimbursements, and other remunerations paid or to be paid to the lobbyist related to the contract B.47.2.2. Not bill or otherwise charge the State for such and B.47.2.3. Certify that no such costs were billed to the State. B.47.3. The name and address of each lobbyist or agent of the vendor, contractor, subcontractor who communicated with a State employee about a proposal or potential proposal must be disclosed with proposal response. C. SOLICITATION SPECIFICATIONS C.1. Introduction C.1.1. The Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS), an agency of the State of Oklahoma, announces the availability of funding for 2 awards for non-medical use of prescription drug (NMUPD) prevention services commencing January 1, 2015 to June 30, 2015. The four subsequent and renewable contract periods will be July 1 through June 30 of each year through September 29, 2019. The contract will support community-based planning and implementation of evidence-based (NMUPD) prevention strategies. C.1.2. Purpose The purpose of this solicitation is aligned with the vision, mission, and goals of the state’s strategic prevention plan1 to create prevention-capable communities in order to: o Prevent the onset and reduce the progression of substance abuse; o Reduce the problems/consequences related to substance abuse; and o Increase prevention capacity and prevention infrastructure at the community level. C.1.2.1. The ODMHSAS intends to achieve this purpose utilizing a public health approach termed hereafter as the Strategic Prevention Framework (SPF).The SPF is a community-based approach to prevention and a series of implementation principles intended to produce population-level outcomes. More information about the SPF model is contained in Attachment 1. C.1.2.2. The state intends to fund no more than eleven eligible suppliers to:

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C.1.2.2.1. Plan and implement a targeted non-medical use of prescription drug prevention initiative among persons aged 12- 25 in a single community/county site. The counties of focus are listed in Attachment 2. Bidders desiring to serve more than one of the eligible communities shall prepare and submit one application per community. Responses for multiple communities shall not be combined. C.1.3. Background C.1.3.1. The Problem Alcohol and other drug consumption is a serious public health problem in Oklahoma driving a multitude of community problems and social consequences. According to the Oklahoma State Epidemiological Outcomes Workgroup (SEOW), a group that compiles and reports on state alcohol and other drug consumption and consequence data, Oklahoma is above the national average in: C.1.3.1.1. Crimes related to drugs C.1.3.1.2. Alcohol-related mortality C.1.3.1.3. Crimes related to alcohol C.1.3.1.4. Tobacco use C.1.3.1.5. Tobacco-related deaths C.1.3.1.6. Illicit and prescription drug use among persons age 12 and older C.1.3.1.7. Drug poisoning deaths C.1.3.2. While the state has achieved marked improvements on certain indicators, the Oklahoma SEOW reports that Oklahoma is experiencing a rise in NMUPDs. C.1.3.3. Oklahoma’s Approach to Prevention: To prevent the onset and prevent/reduce the problems associated with the NMUPDs among persons aged 12-25, Oklahoma will work from a theory of change that is supported through research. Research has shown changing population behavior requires targeting resources to issues influencing that behavior (intervening variables, or risk or causal factors). Once these issues have been identified, a comprehensive set of state and community evidence‐based strategies can be selected and employed. C.1.3.4. State Priority: The State conducted a thorough review of available alcohol and other drug consumption and consequence data, and identified the NMUPDs among persons aged 12-25 as the priority for this RFP. It is the intention of the ODMHSAS to fund prevention services that address this defined priority at the community level. It is the responsibility of the Supplier to conduct a local-level needs assessment to determine the intermediate variables, or risk or causal factors that will be addressed. SPF-PFS Priority Construct Indicator/Measure Non-medical use of prescription pain relievers in the past Nonmedical Use of month among persons aged 12 - 25 Prescription Drugs Opioid Overdose Deaths per 100,000 population among persons aged 12 - 25 C.1.4. Eligibility C.1.4.1. Eligible Suppliers are domestic public and private nonprofit entities. For example, local or state governments; Federally or State recognized Indian Tribes; institutions of higher learning; community- and faith-based organizations; coalitions with 501© tax-exempt nonprofit status; and tribal organizations may apply. C.1.4.2. If a Federally or State recognized Indian Tribe is recommended for award, the award is contingent upon the Tribe receiving written approval of the Joint Committee on State-Tribal Relations authorized in Title 74 Chapter 35A Section 1221. If the approval of the Joint Committee on State Tribal Relations is not obtained in a timely manner (no more than 45 days from notification of the recommendation of award), the ODMHSAS, through the DCS, may award the contract to the next highest scoring bidder. It is the Tribe’s responsibility to obtain the written approval from the Joint Committee on State-Tribal Relations. C.1.5. Funding

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C.1.5.1. Source of Funding: Funding for this contract is contingent upon availability of state and/or federal funding. This contract is for one scope of service, which will be jointly funded by two different funding sources. Funding Source Scope of Service Substance Abuse and Mental Health Services Administration SPF-PFS (SAMHSA), Center for Substance Abuse Prevention (CSAP) Services Strategic Prevention Framework Partnerships For Success (SPF-PFS) cooperative agreement (CFDA Number 93.243) Oklahoma State Prescription Drug Abuse Prevention SPF-PFS Appropriation Services C.1.5.2. Funding Amounts: The State reserves the right to amend contract funding amounts. Funding for this contract is contingent upon availability of state and/or federal funding. The ODMHSAS will recommend to the Department of Central Services a maximum of eleven contract awards in the State of Oklahoma. The maximum eligible funding amounts are listed in Attachment 2. C.1.5.2.1. Funding for SPF-PFS Services: The ODMHSAS will contract with Suppliers to implement the SPF-PFS and provide evidence-based prevention services up to two communities from the four eligible communities listed in Attachment 2 The estimated award amount for each of the two communities shall be up to $90,000.00 per contract per fiscal year as listed in Attachment 2. C.2. Expectations C.2.1. In order to fulfill the purpose of this solicitation, the ODMHSAS expects grantees to systematically: Assess their communities’ prevention needs based on epidemiological data; Build community prevention capacity; Develop strategic plan(s); Implement effective community prevention policies, practices, programs; and Evaluate their efforts for outcomes. C.2.1.1. It is the expectation of the ODMHSAS that all recipients of funds from this solicitation will implement the required services in active partnership with relevant coalitions and community stakeholders. C.2.2. Use of Evidence-Based Practices C.2.2.1. This solicitation is intended to fund prevention strategies that have a demonstrated evidence base and that are appropriate for targeted communities/populations. An evidence-based practice (EBP) refers to approaches to prevention that are validated by documented research evidence. C.2.2.2. Suppliers shall use the criteria developed by the Oklahoma EBP Workgroup and the ODMHSAS when developing strategic plan(s). The criteria for determining level of evidence are listed in Attachment 3. To achieve population-level outcomes, Suppliers will be required to implement evidence-based environmental prevention strategies (those strategies identified in the “Community Domain” section of Attachment 4), which are those policies or practices that create a community or cultural environment that supports healthy and safe behavior. Other strategies in Attachment 4 that are not part of the “Community Domain” are considered supplemental and may be considered after award. C.2.3. Requirements C.2.3.1. Moving SAMHSA’s Strategic Prevention Framework (SPF) from vision to practice is a strategic process that the Supplier and community stakeholders must undertake in partnership. Supplier shall provide the leadership, technical support and monitoring to ensure that the communities of focus are successful in implementing the five steps of the framework listed below. Supplier shall complete required activities for each step of the SPF process at the SPF-PFS community site levels. Supplier shall use the SPF to guide all prevention activities throughout the focus community and coordinate and/or leverage all prevention resources whether funded though the SPF-PFS or through other sources. C.2.3.2. This contract shall be executed consistent with the five steps of the SPF at the SPF-PFS community site levels. Suppliers will have up to six months from the date of contract award to complete, submit and receive approval of the SPF-PFS site strategic plan, before commencing implementation of their strategy (ies).

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C.2.3.3. The ODMHSAS will provide direct support to the Suppliers to fulfill the requirements of this contract. However, the Suppliers are viewed as the primary deliverer of guidance and expertise to the community coalitions. The following requirements and guidelines lay out the five steps of the SPF as they pertain to this contract. C.2.3.3.1. Step1: Profile population needs, resources, and readiness to address the problems and gaps in service delivery. C.2.3.3.2. Step 2: Mobilize and/or build capacity to address needs. C.2.3.3.3. Step 3: Develop a comprehensive Strategic/Work Plan. C.2.3.3.4. Step 4: Implement evidence-based prevention policies, programs and practices and infrastructure development activities. C.2.3.3.5. Step 5: Monitor process, evaluate effectiveness, sustain effective programs/activities, and improve or replace those that fail. C.2.4. Data Collection and Evaluation C.2.4.1. SPF-PFS level evaluation activities shall include all ODMHSAS and SAMHSA data collection and reporting requirements. These activities may include, but are not limited to, participation in a rigorous evaluation, including process and outcome assessments as specified in the final evaluation plan developed between the Supplier and the State evaluation team; collection of National Outcome Measures (NOMs); and participation in the SAMHSA required Cross Site Evaluation and any other SAMHSA required evaluations. C.2.4.2. In an effort to improve the validity and reliability of data required for the evaluation of the community project, the ODMHSAS is requiring Suppliers with an Oklahoma Prevention Needs Assessment (OPNA) student survey response rate of less than 70% to receive technical assistance from the ODMHSAS to improve their response rate to 70% or more. C.3. Statement of Work - Strategic Prevention Framework - Partnerships For Success C.3.1. Supplier shall provide the resources necessary to execute the work requirements detailed in Section C.3. Supplier shall use the SPF process In the provision of all services. C.3.1.1. General Requirements C.3.1.1.1. Supplier Branding C.3.1.1.1.1. Supplier shall identify itself as an ‘Oklahoma SPF-PFS project’ in all correspondence when business is conducted under this award and shall be part of the Oklahoma Prevention Network. C.3.1.1.1.2. SPF-PFS Supplier shall cite SAMHSA (Substance Abuse and Mental Health Services Administration), CSAP (Center for Substance Abuse Prevention) and the ODMHSAS (Oklahoma Department of Mental Health and Substance Abuse Services) as its funding source on all prevention publications, marketing materials, websites, and public reports. C.3.1.1.2. Prevention Message and Sponsorship C.3.1.1.2.1. Supplier shall ensure the prevention message it provides in the delivery of all services by stating that “No illegal use of alcohol, tobacco, and other drugs (ATOD) shall be allowed or encouraged. Any excessive or abusive use of legal drugs by those of age will also be discouraged, including the abuse of pharmaceuticals. Curricula, strategies or messages used by Supplier shall not contain messages such as “some illicit drugs may not be as dangerous as others.” C.3.1.1.2.2. Supplier shall ensure that no prevention messages, curricula, programs, strategies, materials, speakers, presentations, sponsorships and/or contracts with entities associated with or receiving funds from tobacco or alcohol industries are used in the delivery of prevention services. Supplier agrees to obtain prior approval from the ODMHSAS for any and all questionable situations. In addition, Supplier agrees not to receive funds from said industries. C.3.1.1.3. Service location C.3.1.1.3.1. Supplier shall maintain a physical presence during the contract in the service community that is clearly visible to the public. A physical presence must minimally include a consistent staff presence in the service community with easy access for the public and a local phone number. A physical presence may also include branded office space, branded meeting space, branded linkages to existing public service locations (i.e. United Way, municipal buildings) or other branded, physical means of connecting the Supplier to the service community.

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C.3.1.1.3.2. Supplier shall provide, schedule, or otherwise arrange all sites, facilities, facility management, supplies and other resources necessary to provide program services or scheduled activities or events. Supplier may utilize multiple sites and/or locations within the affected service region(s). Program sites, facilities, and locations for all service categories shall be readily accessible by all participants and interested community members and shall be appropriate for the activity conducted. All sites and facilities shall also be physically and programmatically accessible to the disabled, pursuant to requirements of the Americans with Disabilities Act (ADA). C.3.1.1.4. Staff Requirements C.3.1.1.4.1. Level of Effort: Supplier shall recruit, hire and maintain a minimum of one full-time equivalency (FTE) staff who will serve as the SPF-PFS Coordinator. The SPF-PFS Coordinator shall be the primary contact person and responsible for the daily operations associated with the project. The SPF-PFS Coordinator shall dedicate 100% of their time to this contract. Supplier may submit a request with justification in the RFP for a less than 100% SPF-PFS Coordinator but not less than 75%.The SPF-PFS Coordinator shall be hired within 45 days of contract start.. C.3.1.1.4.2. Experience and Qualifications: Staff shall have the knowledge and experience necessary in planning and implementing alcohol, tobacco and/or other drug prevention strategies. Supplier shall demonstrate evidence of the minimum range of experience and skills within the proposed program staffing. The staff shall demonstrate at least one year prevention, behavioral health, or public health related experience to include one or more environmental prevention strategies and obtain Certified Prevention Specialist (CPS) for Bachelor level staff, or Associate Prevention Specialist (APS) for non-degreed staff certification, through the Oklahoma Drug and Alcohol Professional Counselor Association (ODAPCA) within 18 months of employment start date or contract award, whichever is longer. Resumes shall be submitted for all positions post award. C.3.1.1.4.3. All positions shall require knowledge of the underlying principles of the public health approach to alcohol, tobacco and/or other drug problems; knowledge of the underlying principles and application of environmental strategies that advance policy-based prevention approaches to reduce alcohol, tobacco, and/or other drug problems; knowledge and competency in organizing, developing and sustaining community-based collaborations aimed at achieving environmental change; knowledge of the underlying principles of the use of media advocacy to reduce alcohol, tobacco or other drug problems; and knowledge of the purpose and function of multi-system collaboration to affect organizational and systems changes to reduce alcohol, tobacco and other drug problems in communities. C.3.1.1.4.4. Background Checks: Supplier shall ensure background checks on all staff and volunteers are conducted and shall maintain documentation of such checks. At a minimum, background checks shall search records from the Oklahoma State Bureau of Investigations. All staff and volunteers working with minor children shall, at a minimum, meet the statutory requirements proscribed by Oklahoma State law and demonstrate said personnel has no felony convictions, crimes of moral turpitude, or alcohol or drug-related offenses. If Supplier has staff or volunteers with felony convictions, crimes of moral turpitude, or alcohol or drug-related offenses, Supplier shall have a policy that provides for review of the consideration of the possible benefit of the applicant, employee, or volunteer along with the possible risk as evidenced by previous criminal activity. C.3.1.1.4.5. Professional Development: Supplier shall ensure that all staff completes Substance Abuse Prevention Skills Training (SAPST) and other relevant new staff training within 12 months of employment. C.3.1.1.4.6. Professional Development For Out of State Travel: Supplier shall ensure that out of state travel for professional development purposes shall be limited to one (1) workshop, training or conference per funded project staff per fiscal year upon prior approval by the ODMHSAS. The ODMHSAS may reimburse the registration fee for up to one additional out of state event per fiscal year. Supplier shall submit written justification to the ODMHSAS no later than 30 days prior to the event. Exceptions may be reviewed and determined at the discretion of the ODMHSAS with proper written justification. The ODMHSAS may identify out of state training that necessitates/warrants attendance and, in that case, may obviate this provision. C.3.1.1.4.7. Staff Conduct: Supplier shall ensure all staff adhere to the Oklahoma Drug and Alcohol Professional Counselor Association’s Preventionist Code of Ethics and maintain professional conduct and presentation at all times when executing the duties of the contract.

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C.3.1.1.5. ODMHSAS Trainings/Meetings C.3.1.1.5.1. Supplier shall attend all mandatory ODMHSAS and SPF-PFS prevention trainings. There will be a minimum of two trainings. C.3.1.1.5.2. Supplier shall attend all provider meetings offered by the ODMHSAS. There will be approximately two provider meetings. C.3.1.1.5.3. Supplier shall participate in all provider conference calls offered by the ODMHSAS. There will a minimum of six conference calls per year. C.3.1.1.6. Program Participant Protection C.3.1.1.6.1. Supplier shall obtain written consent from a parent or legal guardian prior to transporting minor children for activities conducted under the contract. C.3.1.1.6.2. Supplier shall obtain written consent from a parent or legal guardian prior to participation of minor children in activities, including evaluation or research, conducted under the contract. C.3.1.1.6.3. Supplier shall retain documentation of parental/legal guardian consent and make available for review as requested by the ODMHSAS. C.3.1.1.7. Revision and Change Requests C.3.1.1.7.1. Since the approved strategic plan(s) and work plan(s) serve as the Supplier’s contractual requirements, Supplier shall request written, prior approval from the ODMHSAS to revise the strategic plan(s) and/or work plan(s). The ODMHSAS shall evaluate if the proposed change is justified. Proposed revisions must be in accordance with project guidelines. Supplier shall not proceed with the delivery of new services or re- direction of resources until the revision has been approved by the ODMHSAS in writing. C.3.1.1.7.2. Supplier agrees that any changes required by the Department, or reached by means of Supplier and Department negotiations regarding the services, activities, and programs contained in the program plan, shall be reflected in a revised strategic plan, work plan, budget, and budget narrative. C.3.1.2. Services C.3.1.2.1. Needs Assessment: C.3.1.2.1.1. Community Data Workgroup (CDW): Supplier with the active participation of the partner coalition shall develop a Community Data Workgroup (CDW) to collect and analyze community level data. The CDW may be a workgroup within the partner coalition. The CDW will continue its work throughout the duration of the project to produce an annual Community Epidemiological Profile (CEP) and support ongoing monitoring and evaluation including OPNA recruitment and participation. C.3.1.2.1.2. Regional Epidemiological Outcomes Workgroup (REOW): Supplier with active participation of the CDW shall actively participate on the REOW convened by the relevant Regional Prevention Coordinator (RPC). Supplier shall ensure data on the SPF-PFS priority are collected and analyzed as part of the REOW process C.3.1.2.1.3. Within five months of the contract start, Supplier with the active participation of the partner coalition and CDW shall complete a community epidemiological profile specific to the SPF-PFS priority in a format prescribed by the ODMHSAS. The profile shall include identification of the selected SPF-PFS priority indicator, community site, and needs/causal factor assessment findings. Supplier shall complete an annual SPF-PFS CEP update each contract year thereafter. C.3.1.2.1.4. Area of service coverage for each contract is the whole county. C.3.1.2.2. Capacity Building (Coalition): C.3.1.2.2.1. Within three months of the contract award Supplier shall establish a Memorandum of Understanding (MOU) with one community coalition for the entire contract period in the selected SPF-PFS community. The coalition must be located in the SPF-PFS community and agree to: (1) allow the SPF-PFS staff to provide capacity building services for the coalition and the community; and (2) plan, implement, and evaluate the SPF-PFS strategic plan. If coalitions do not exist in the SPF-PFS community or are not the appropriate fit for the SPF-PFS priority, Supplier shall pursue development of a coalition. C.3.1.2.2.2. Supplier shall conduct a baseline coalition capacity, and baseline community readiness assessments with the SPF-PFS coalition within six months of contract start, and annually

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thereafter, during the contract period. Supplier shall document the coalition’s capacity and the community’s readiness on a scale. C.3.1.2.2.3. Supplier shall be responsible for providing training and technical assistance to the partner community coalition and documenting coalition progress/participation. Out of state travel for coalition members and/or strategic partners to attend workshops, trainings or conferences shall require prior written approval from the ODMHSAS. Supplier shall submit proper written justification in an ODMHSAS prescribed format for the out of state travel that states how the training will advance the community’s work on the priority issue and the specific plans to transfer learned knowledge and skills to the coalition(s). C.3.1.2.2.4. Supplier shall provide technical assistance to the SPF-PFS coalition to develop partnerships in each of the community sectors relevant to the priority issue and selected evidence based strategy. C.3.1.2.2.5. Supplier shall identify strategic community constituents necessary to advance the community strategic plan. Supplier shall establish partnership/relationship benchmarks related to the prioritized indicators in the community strategic plan and document progress advancing the partnership in a format prescribed by the ODMHSAS. The ODMHSAS may prescribe required sectors/partners. C.3.1.2.3. Planning: C.3.1.2.3.1. Within eight months of contract start Supplier shall develop a comprehensive community strategic plan. The strategic plan must be data-driven and utilize environmental evidence-based approaches. Planning shall be conducted in active collaboration with the SPF-PFS partner coalition. C.3.1.2.3.2. Implementation of services shall not commence until the ODMHSAS approves the community strategic plan, and work plan(s). The strategic plan shall be in a format prescribed by the ODMHSAS and shall include: C.3.1.2.3.2.1. Needs assessment (community epidemiological profile and causal factor/intermediate variables assessment) C.3.1.2.3.2.2. Identification of priority SPF-PFS indicator and community of focus C.3.1.2.3.2.3. Identification of partner coalition/constituents and plan to advance readiness, capacity, and partnerships C.3.1.2.3.2.4. Identification of selected evidence-based practices C.3.1.2.3.2.5. Logic Model C.3.1.2.3.2.6. Goals, measureable objectives, tasks, timelines C.3.1.2.3.2.7. Work Plan C.3.1.2.3.2.8. Sustainability plan C.3.1.2.3.2.9. Cultural competency plan C.3.1.2.3.2.10. Disparity Impact Statement C.3.1.3. Post Strategic Plan Approval Services Supplier shall initiate work on the following requirements upon completion of, and approval by the ODMHSAS, of the SPF-PFS strategic plan. C.3.1.3.1. Capacity Building (community and coalition):

C.3.1.3.1.1. Supplier shall be responsible for providing training and technical assistance to the SPF- PFS coalition and documenting coalition progress/participation in a format prescribed by the ODMHSAS. C.3.1.3.1.2. Supplier shall conduct a regular (at minimum, annually) community readiness assessments during the contract period. Supplier shall document the community’s progress on a readiness scale. C.3.1.3.1.3. Supplier shall conduct regular (at minimum, annually) coalition capacity assessment during the contract period. Supplier shall document the coalition progress on a capacity scale for supporting SPF-PFS strategic goals. C.3.1.3.1.4. Supplier shall conduct a minimum of one SPF and one priority issue training to the SPF- PFS coalition annually.

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C.3.1.3.1.5. Supplier shall document relationship development with identified strategic partners/constituents and how the relationship advances strategic goals. C.3.1.3.1.6. Supplier shall continue to engage the coalition in developing and/or strengthening its capacity (leadership, membership, functions, bylaws, roles and responsibilities, etc.). C.3.1.3.2. Implementation: C.3.1.3.2.1. Supplier shall adhere to the strategic plan approved by the ODMHSAS for the SPF-PFS project and shall utilize SPF-PFS funds to implement only the approved strategies in the work place. C.3.1.3.2.2. Supplier shall ensure that the partner coalition leadership approves, with a written signature, the required documents including the community data profile, strategic plan, work plan(s), project budget, MOUs, evaluation plan, quarterly reports, and other documents as may be requested by the ODMHSAS. C.3.1.3.2.3. Supplier shall support the coalition in its efforts to carry out the implementation of evidence-based or effective strategies that address the local priority in a culturally competent and sustainable manner while maintaining fidelity. C.3.1.3.2.4. Supplier shall ensure that the coalition implements the approved strategies within the targeted community area and identified population of focus. C.3.1.3.2.5. Supplier shall ensure that the selected evidence-based strategies are implemented with fidelity. C.3.1.3.3. Evaluation: C.3.1.3.3.1. Supplier shall participate in all mandatory evaluation activities including the submission of reports and other information within the designated timeframe and in a format prescribed by the ODMHSAS. C.3.1.3.3.2. Supplier shall participate in the development of a local evaluation plan in collaboration with the SPF-PFS State Project Evaluator. C.3.1.3.3.3. Supplier shall complete the federally required data collection instruments according to the guidelines and timeframes established by the CSAP and/or its Supplier. C.3.1.3.3.4. Supplier shall report annually the NOMs relevant to its community plan. The Department must approve all instruments and methods to collect the NOMs. C.3.1.3.3.5. Supplier shall participate in face-to-face interviews, phone interviews, site-visits, on-line surveys, paper/pencil surveys, and/or other data collection activities conducted by the ODMHSAS and/or its contracted State Project Evaluator. C.3.1.3.3.6. If the Supplier chooses to use any data collection instrument other than those provided by the ODMHSAS, all project requirements are applicable to that survey and the ODMHSAS must first review and approve the instrument. C.3.1.3.3.7. Supplier shall collect all relevant process evaluation data as prescribed by the ODMHSAS. Process data includes, but is not limited, to sign-in sheets, proof of strategy implementation, satisfaction surveys, training handouts, and certificates of participation. C.3.1.3.3.8. Supplier shall maintain documentation related to the planning (assessment or development of the local strategic plan) and delivery of services (e.g. coalition meeting minutes, agendas, coalition rosters, etc.). This documentation is subject to random audits by the ODMHSAS throughout the fiscal year. C.3.1.4. Performance Monitoring C.3.1.4.1. Supplier shall submit all progress reports within 15 days of the end of each quarter in a format prescribed by the ODMHSAS. C.3.1.4.2. Supplier shall complete other reports and forms determined necessary for documenting the implementation of the SPF process, strategies, and the community strategic plan. C.3.1.4.3. Supplier shall maintain documentation of all grant related activities. These documents are subject to review by the ODMHSAS. C.3.1.5. Milestone Timeline C.3.1.5.1. The following table outlines key contract milestones for Fiscal Year 2015 (January 1, 2015 – June 30, 2015). Supplier shall comply with this timeline and subsequent revisions by the ODMHSAS. Note that not all contract deadlines are included in this table. Milestone Deadline

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Project staff hired Within 45 days after award Coalition identified w/agreement Within 3 months after award Community Data Workgroup Within 4 months after award (CDW) Convened Coalition/CDW Orientation 5 months after award Community Readiness & Coalition 6 months after award, annually Capacity Assessment Completed thru Year 5 Complete assessment of 7 months after award community-level intervening variables/community conditions related to project goals Strategic plan submitted 8 months after award Workplan plan (with Disparity 9 months after award Impact Statement) submitted Evaluation plan submitted 9 months after award Coalition training Bi-annually Implementation commenced No earlier than approval of strategic plan Reports submitted No later than 15 days after each quarter ends *Represents recommended timeframe D. EVALUATION D.1. Solicitations meeting the minimum Supplier’s qualifications and all material requirements of the RFP will be evaluated based on the following best value criteria, which are listed in order as follows: D.1.1. Project Abstract D.1.2. Project Narrative D.1.2.1. Needs Assessment D.1.2.2. Capacity D.1.2.3. Planning/Implementation D.1.2.4. Evaluation D.1.3. Supporting Documentation D.1.3.1. Project Budgets D.1.3.2. Job Descriptions/Biographical Sketches D.1.3.3. Letters of Commitment D.1.4. Face to face interview conducted as part of the RFP review. Suppliers that meet all of the requirements will qualify for an interview. D.2. A score of 70% or higher on the narrative and interview may be recommended for award. If there is more than one Supplier bidding for the focus community, the Supplier with the highest percentage score over 70% may be recommended for award. If no Suppliers reach the 70% or higher range; but, there is a Supplier in the “close” range (i.e. 68-69%), that Supplier may be recommended for award. E. INSTRUCTIONS TO SUPPLIER E.1. Introduction Prospective Bidders are urged to read this solicitation carefully. Failure to do so will be at the Bidder’s risk. Provisions, terms, and conditions may be stated or phrased differently than in previous solicitations. Irrespective of past interpretations, practices or customs, proposals will be evaluated and any resultant contract(s) will be administered in strict accordance with the plain meaning of the contents hereof. The Bidder is cautioned that the

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requirements of this solicitation can be altered only by written amendment approved by the state and that verbal communications from whatever source are of no effect. In no event shall the Bidder’s failure to read and understand any term or condition in this solicitation constitute grounds for a claim after contract award. E.1.1. MANDATORY AND NON-MANDATORY TERMS E.1.1.1. Whenever the terms “shall”, “must”, “will”, or “is required” are used in this RFP, the specification being referred to is a mandatory specification of this RFP. Failure to meet any mandatory specification may cause rejection of the Bidder’s Proposal. E.1.1.2. Whenever the terms “can”, “may”, or “should” are used in this RFP, the specification being referred to is a desirable item and failure to provide any item so termed will not be cause for rejection. E.2. Submissions/Copies E.2.1. Contractor is to submit SIX (6) complete copies of their response on SIX (6) separate CDs or DVDs (one copy on each Disc) which includes the completed proposal, including the scanned images of the OMES signed forms. Disc must be an unprotected document. E.2.2. Original hard copies are not required or preferred. This overrides hard copy submittal requirements of A.2.4. E.2.3. Please ensure that your Discs are marked clearly with the RFP Number. E.2.4. PDF is an acceptable format for solicitation responses. This overrides requirements of A.2.4 E.3. Questions E.3.1. All questions regarding this solicitation must be submitted in writing and are to be emailed to no later than 3:00pm CST Friday, January 23, 2014. Questions are to be emailed to [email protected]. Questions received after this date will not be answered. An Amendment will be posted after this deadline listing all questions received and their answers. E.4. From the issue date of this RFP until a successful Supplier is selected and the selection is announced, Suppliers are not allowed to communicate regarding this RFP with any State staff or any individuals who were involved in developing this solicitation except through the Contracting Officer named herein unless otherwise indicated herein. For violation of this provision, the Supplier’s proposal would be considered non-responsive. E.5. Amendments to RFP E.5.1. Any amendment to this RFP shall become part of this RFP and part of any contract resulting from this RFP. The Supplier shall acknowledge receipt of any and all amendments to the RFP. It is the sole responsibility of the Supplier to be knowledgeable of all amendment(s) related to this solicitation. E.6. Offering Employee Positions E.6.1. Consideration and additional weight will be given to the Suppliers ho offer employment to employees of the SPFSIG project who are currently contracted with the ODMHSAS (during state fiscal year 2015); provided however, that the employees meet the reasonable hiring criteria of the Supplier. E.7. Response Preparation and Submission E.7.1. General E.7.1.1. Bidders desiring to serve more than one of the eligible communities shall prepare and submit one application per community. Responses for multiple communities shall not be combined. The Supplier is to follow instructions contained in this RFP in preparing and submitting its solicitation response. The Supplier is advised to thoroughly read and follow all instructions. The information required to be submitted in response to this RFP has been determined to be essential in evaluation and contract award process. All responses submitted become the property of the State of Oklahoma and will not be returned. E.7.2. Solicitation Contents E.7.2.1. If a Supplier discovers any significant ambiguity, error, conflict, discrepancy, omission, or other deficiency in this RFP, the Supplier must immediately notify (notification must be completed in a timeframe specified in section E.2) the Contracting Officer named in section E.1.1 in writing of such error and request modification or clarification. If Central Purchasing Division issues an amendment or clarification, it will be posted on the website. E.7.2.2. If, prior to the deadline for submission of questions, a Supplier fails to notify the Contracting Officer of a known error or omission in the RFP or an error that reasonably should have been

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known to the Supplier and if a contract is awarded to the supplier, the Supplier shall not be entitled to additional compensation or time by reason of the error or its later correction. E.7.2.3. Supplier should note that this solicitation reflects those changes in the existing operation to increase efficiencies and streamline business environment in the State of Oklahoma. All previous solicitations or resultant contracts should not be either depended upon, perceived or interpreted to have any relevance on this exclusive solicitation. E.7.2.4. It is imperative that each supplier realizes that what is written in Supplier’s proposal, discussed in the interview process and kick-off meeting(s), asked to be submitted from kick-off meeting(s), and any negotiations (if needed) will become part of the successful Supplier’s final response and part of the contract documents. E.7.3. Response Format E.7.3.1. The response should be typewritten on standard 8 1/2 x 11 inch paper, in 11 point font, with one-inch margins, single spaced, single sided, with numbered pages, and stapled in the top left margin. Suppliers should not bind or use any materials such as folders, binders, or paper clips and the like. The response should be prepared simply and economically in strict accordance with the format and instructional requirements of this solicitation. Responses should be a concise delineation of the Supplier’s capabilities to satisfy the requirement of the information requested, with emphasis on completeness and clarity of content. E.7.3.2. All Suppliers are required to present responses using the same headings, categories and sequence as outlines in this RFP to ensure a fair, equitable, and timely evaluation. The State reserves the right to reject any and all responses submitted that fail to conform to the requirements of the RFP and to request additional information from any Supplier submitting a response. Suppliers must ensure that proposals are current and accurate. Incomplete responses or responses that are not prepared in accordance with this RFP may be eliminated from the evaluation process. E.7.4. Response Content Overview E.7.4.1. the following table describes the format and order of the solicitation response. The Project Narrative, Sections 1-4, shall not exceed 15 pages. Suppliers must label in order proposals using the following format: Section/Subsection Title: Maximum Page Limit Cover Page 1 page Table of Contents 1 page Project Abstract 1 page (not to exceed 350 words) Project Narrative (Sec 1-4): 15 pages Section 1: SPF-PFS Site Needs Assessment Sections 1-4, not to exceed 15 pages

Section 2: Capacity 2A: Organizational Capacity 2B: Coalition Capacity 2C: Community Readiness Section 3: Project Planning/Implementation Section 4: Evaluation Section 5: Project Budgets No limit Appendix A: Job Descriptions/Biographical 1 page each Sketches (resumes) Appendix B: Letters of Commitment Minimum of 5 and no limit on maximum amount E.7.5. Detailed Contents of Response E.7.5.1. Cover Page: Include the name, address, and telephone number of Supplier organization. Include the title and signature of the responsible officer. E.7.5.2. Table of Contents: All pages of the proposal, including attachments, should be listed on the Table of Contents page with corresponding page numbers.

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E.7.5.3. Project Abstract: Provide an overview, not to exceed 350 words, of the proposed project that includes: A clear statement of the service community; the approach to accomplishing the required steps (SPF steps 1-5). E.7.5.4. Project Narrative: Suppliers should thoroughly read Sections C.2 – C.3 of this RFP. Responses should reflect a clear understanding and acknowledgment of the requirements and processes described in the RFP as well as intent to work closely with the ODMHSAS to execute the project. E.7.5.4.1. Section 1: Needs Assessment E.7.5.4.1.1. SPF-PFS Community Needs Assessment E.7.5.4.1.1.1. Identify the area to be served. Provide a description of the SPF-PFS community: • Geographic area • Demographic information, including • socioeconomic factors • Tribal governments and citizenry • School districts, municipalities • Prescription drug abuse prevalence • Cite all sources of information provided. E.7.5.4.1.2. Describe how the intermediate variables or risk or causal factors for the SPF-PFS (C.1.3.4) will be assessed. Describe the data sources that will be used. E.7.5.4.1.3. Describe the data gaps that exist at the local level related to the SPF-PFS priority. Describe other barriers that exist or are foreseen and how you will overcome those barriers. E.7.5.4.1.4. Describe what resources and community partnerships exist to conduct the needs assessment. Describe plans for securing resources and developing the partnerships needed to conduct the needs assessment. E.7.5.4.1.5. Describe the SPF-PFS community’s OPNA data relevant to the NMUPD priority, and what the OPNA survey response rate is for the SPF-PFS community. If the response rate is less than 70%, describe how the Supplier plans to increase the response rate to 70%. E.7.5.4.2. Section 2: Capacity E.7.5.4.2.1. Organizational Capacity E.7.5.4.2.1.1. Describe the capability and experience of the Supplier organization with similar projects. Outline the organization’s specific experience providing community-based prevention services. E.7.5.4.2.1.2. Describe the organization’s theoretical framework for prevention. Provide an acknowledgement to adhere to the SPF process with fidelity. Demonstrate a clear understanding of and organizational alignment with the ODMHSAS strategic plan for prevention. E.7.5.4.2.1.3. Describe the Supplier organization’s experience providing culturally- appropriate/ competent services. E.7.5.4.2.1.4. Describe the Supplier organization’s experience serving the proposed area. If no/limited prior experience exists, describe the proposed approach for developing community partnerships E.7.5.4.2.1.5. Provide a detailed explanation of how the Supplier organization will demonstrate a strong community presence in the area to be served. If a physical office space is not proposed, explain and justify the organization’s plan for a consistent, highly visible presence in the SPF-PFS community to be served. E.7.5.4.2.1.6. Provide a statement of confirmation that the Supplier organization will offer employment to employees of RPCs who worked on the SPFSIG project provided that the employees meet the reasonable hiring criteria of the Supplier. E.7.5.4.2.1.7. Identify all key staff for the project and their demonstrated experience/qualifications as outlined in Sections C.3 (Statements of Work). Specify the SPF-PFS Coordinator. Provide biographical sketches and job descriptions (resumes) in Section 6. Provide an organizational chart, showing lines of supervision for the SPF-PFS project to the organization’s leadership.

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E.7.5.4.2.1.8. Describe how program continuity will be maintained when there is a change in the operational environment (e.g., staff turnover, change in project leadership) to ensure stability over time. E.7.5.4.2.1.9. Describe any in-kind and other resources that will be used to carry out the project. E.7.5.4.2.2. Coalition Capacity E.7.5.4.2.2.1. Identify all key community/youth coalitions, task forces, or committees (include all current Drug Free Communities grantees) in place to address substance abuse prevention within the SPF-PFS community. Describe the groups’ histories, members/sectors represented, and missions. If no coalition exists in the SPF-PFS community, describe the process to be used to develop a coalition. E.7.5.4.2.2.2. Provide letters of commitment from key community coalitions and community stakeholders demonstrating their experience with the Supplier organization and/or agreement to collaborate on the project. There should be a minimum of 5 letters, and the letters should be included as Appendix B. E.7.5.4.2.2.3. Describe the general capacity strengths and weaknesses that exist (related to impacting community-level change using the SPF) within the identified community coalition and your planned approach to build capacity to address gaps. If strengths and weaknesses are unknown, describe the proposed plan to assess prevention capacity with the coalitions. E.7.5.4.2.2.4. Note: A specific plan to develop coalition capacity will be developed and submitted if contract is awarded. E.7.5.4.2.2.5. Describe the Supplier organization’s experience providing prevention capacity building services to coalitions. E.7.5.4.2.2.6. Describe the proposed plan to measure the partner coalition prevention capacity change throughout the project period. E.7.5.4.2.3. Community Capacity E.7.5.4.2.3.1. Describe the proposed plan to measure community readiness for supporting the SPF-PFS strategic goal, and a plan for increasing community readiness. E.7.5.4.3. Section 3: Project Planning/Implementation E.7.5.4.3.1. Discuss the role of the SPF-PFS staff and the role of the partner community coalition in planning and implementing the project. E.7.5.4.3.2. Describe the role of the SPF-PFS staff with the ODMHSAS in planning and implementing the project. E.7.5.4.3.3. Describe the Supplier organization’s experience implementing evidence-based prevention services. Specifically outline experience implementing environmental prevention and policy-based services. E.7.5.4.3.4. Describe the process that will be used to identify evidence-based policies, programs, or practices for this project. Explain the Supplier organization’s protocol and/or theoretical framework for selecting evidence-based practices. Include discussion of cultural relevance, fidelity, and how the Supplier will support the partner coalition in this process. E.7.5.4.3.5. Describe how the project will address issues of age, race, ethnicity, culture, language, sexual orientation, disability, literacy, and gender in the populations of focus. E.7.5.4.3.6. Describe the proposed approach to project sustainability. E.7.5.4.4. Section 4: Evaluation E.7.5.4.4.1. Demonstrate agreement to comply with all local, state, and federal evaluation requirements for this project. E.7.5.4.4.2. Describe the Supplier organization’s experience conducting evaluations, including process and outcome evaluation. E.7.5.4.4.3. Document your ability to collect and report on the required performance measures. E.7.5.4.4.4. Describe the plan for tracking and reporting the data generated by the project over time, and utilizing these data in the ongoing project planning, development, and quality assurance.

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E.7.5.4.4.5. Explain how the Supplier organization will provide the resources necessary to fulfill the evaluation requirements for this project (i.e. evaluator on staff/project team, etc.). E.7.5.4.5. Section 5: Project Budgets E.7.5.4.5.1. Important: Complete a project budget for the SPF-PFS project for Fiscal Year 2015 (January 1, 2015 – June 30, 2015). The budget format template is provided in Attachment 5. E.7.5.4.5.2. All costs identified in the project budgets must be in accordance with the Allowable/Unallowable Costs outlined in Attachment. The proposed costs must be in accordance with Section 34 CFR Subtitle A §80.22 Allowable costs. E.7.5.4.5.3. A justification for each item in the projected budgets must be provided. E.7.5.4.5.4. Required budget items: E.7.5.4.5.4.1. Supplier organization must include budget for all required meetings per project year in the Oklahoma City metro area for two persons on the SPF-PFS budget. Include budget amounts for two overnight stays, if needed, for each meeting. E.7.5.4.5.4.2. Supplier organization must include personnel expenses for a full-time SPF- PFS coordinator (or equivalent position within organization). E.7.5.4.6. Appendix A: Job Descriptions/Biographical Sketches (Resumes) E.7.5.4.6.1. Appendix A will be scored in relation to the requirements outlined in Section 2: Capacity. Include a biographical sketch for the SPF-PFS Coordinator and other key positions. Each sketch should not exceed one page. If the person(s) has/have not been hired, include position description(s) and/or a letter(s) of commitment with current biographical sketch(es) from the individual(s). E.7.5.4.6.1.1. Include job descriptions for all proposed personnel. Job descriptions should not exceed one page each. E.7.5.4.7. Appendix B: Letters of Commitment E.7.5.4.7.1. Appendix B will be scored in relation to the requirements outlined in Section 2: Capacity. Responses without Appendix B or those not meeting the stated requirements will not be reviewed. Provide letters of commitment (minimum of 5 and no limit on the maximum number) from those strategic partners within the SPF-PFS community to be served. F. CHECKLIST ____ Cover Page ____ Table of Contents ____ Project Abstract ____ Project Narrative (Sections 1-4): ____ Project Budget – (Description in E, Section 5) ____ Appendix A: Job Descriptions/Biographical Sketches (Resumes) ____ Appendix B: Letters of Commitment ____ Audit-Type Certification attachment ____ Certification for Competitive Bid and/or Contract (Non-Collusion Certification) Form ____ Responding Supplier Information Form G. OTHER NONE H. PRICE AND COST None

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ATTACHMENT 1

Strategic Prevention Framework Principles

The SPF model employs a public health approach that focuses on achieving population- level outcomes. In instituting the SPF process, Oklahoma continues to transform from a focus on services to individuals or small groups of consumers to population-based approaches that view community wellbeing as the unit of outcome measurement, and from agency-centered services to coordinated, multi-sector systems approaches that use evidence-based practices to achieve change.

The following SPF principles are essential in achieving the expected population level change that this solicitation requires. The principles provide broad guidelines that inform each step of the process, from strategic planning and capacity building, through evaluation and sustainability.

The SPF promotes a systems-based approach to substance abuse prevention: Communities and prevention providers work to support the development of a system that has both long- and short-term effects on bringing down the rates of substance abuse. This process involves gradual change over a long period of time. It also calls for communities to work together strategically to foster the principles of cultural competency and sustainability throughout the SPF process

The SPF allows communities to build capacity and sustain a culturally-competent infrastructure: The SPF affords communities the opportunity to assess and mobilize community capacity by engaging workforce, financial, and organizational resources to build prevention infrastructure. In working with diverse populations, the principles of cultural competence can ensure that environments as well as relationships are built on inclusion and mutual respect. By addressing sustainability, communities can ensure the longevity of prevention systems and their program outcomes.

The SPF is an example of outcome based prevention: The SPF is designed to systematically collect, analyze, interpret, and apply findings from epidemiological and community readiness data about substance use and consequences. Understanding the nature and extent of consumption and consequences from the beginning is critical. This data driven process guides community level efforts in identifying problems and setting priorities to determine the selection of policies, practices and programs that can best address issues affecting the health and well-being of communities.

The SPF requires evidence-based programs, policies and practices as the basis for program implementation: Communities are required to implement evidence-based programs to ensure accountability and effectiveness in community-level prevention efforts.

The SPF encourages community-level change: Communities support what they help to create, and local people solve local problems. Within the community, the SPF takes a public health approach to preventing substance related problems. This approach focuses on population-level change (change among groups that have one or more personal or environmental characteristic in common). Implementing the SPF via the five steps gives communities the tools to determine the substance abuse problems affecting their constituents and the most effective strategies to address them. To achieve population-level outcomes, Suppliers will be required to prioritize evidence-based environmental prevention strategies, which are those policies or practices that create a community or cultural environment that supports healthy and safe behavior. Attachment 2: SPF-PFS Priority Community and Amounts in 4 RPC Coverage Areas.

Up to 2 communities will be selected and funded from the 4 communities in the 4 RPC coverage areas below via the bid application process

RPC County Priority Focus Minimum Jan 1 - Region Population Annual June 30, Funding 2015 Amount

3 Pawnee Non Medical Use of Prescription Drugs 12 -25 year $90,000 $45,000 old

2 Garfield Non Medical Use of Prescription Drugs 12 -25 year $90,000 $45,000 old

12 Beckham Non Medical Use of Prescription Drugs 12 -25 year $90,000 $45,000 old

1 Woodward Non Medical Use of Prescription Drugs 12 -25 year $90,000 $45,000 old

* Initial funding January 1, 2015 – June 30, 2015 (6 months) will cover the remaining period of the State Fiscal Year 2015. The annual funding thereafter for subsequent full fiscal years will be a minimum of $90,000 for each supplier. Attachment 3 Evidence-based Workgroup Submission Form

Strategies that Appear on Approved List

Agency Name: ______Date of Submission: ______

Contact Name: ______Contact e-mail: ______

Strategy Name: ______

If the proposed strategy appears on Oklahoma’s registry of evidence based practices, please provide the following:

Attachment 1: ______Logic model displaying the consequence, consumption, intervening variables (risk factors or contributing factors), and direct and indirect populations targeted for change*

*If any of the information provided in Attachment 1 (consequence, consumption, or intervening variables targeted for change) differs from the strategy on approved list, please include research citations to support the others

Attachment 2: ______Implementation plan and timeline

Attachment 3: ______Evaluation plan, tools, and protocols

Attachment 4a: ______If no deviations are planned, describe your plan to ensure fidelity is maintained during implementation (include the following issues)

- Target population of the proposed strategy is similar in demographics and numbers to the researched population

- All elements and facets of the proposed strategy will be implemented

- Implementation timeline and methodology of the proposed strategy is similar to the researched strategy OR

Attachment 4b: ______If your implementation will include deviations from the original implementation, please describe deviations and explain why deviations will not impact the level of effectiveness Attachment 3 Evidence-based Workgroup Submission Form

Strategies that Do Not Appear on Approved List

Agency Name: ______Date of Submission: ______

Contact Name: ______Contact e-mail: ______

Strategy Name: ______

If the proposed strategy does not appear on Oklahoma’s registry of evidence based practices, please attach the following:

Attachment 1: ______Logic model displaying the consequence, consumption, intervening variables (risk factors or contributing factors), and direct and indirect populations targeted for change

Attachment 2a: ______Copy of peer-reviewed journal publications that provide baseline and follow-up (post intervention) data showing that the proposed strategy has been effectively implemented in the past, multiple times, in a manner attentive to scientific standards of evidence and with results that show a consistent pattern of credible and positive effects on consequence, consumption, or intervening variables targeted for change as well as population targeted for change (include journal citation)* OR

Attachment 2b: ______Copy of program developer materials that provide baseline and follow-up (post intervention) data showing that the proposed strategy has been effectively implemented in the past, multiple times, in a manner attentive to scientific standards of evidence and with results that show a consistent pattern of credible and positive effects on consequence, consumption, or intervening variables targeted for change as well as population targeted for change*

*If the information provided in 2a or 2b provides data for only some parts of your logic model (consequence, consumption, or intervening variables targeted for change), please include research citations to support the others

Attachment 3: ______Implementation plan and timeline

Attachment 4: ______Evaluation plan, tools, and protocols

Attachment 5a: ______If no strategy deviations are planned, describe your plan to ensure fidelity is maintained during implementation (include the following issues) - Target population of the proposed strategy is similar in demographics and numbers to the researched population - All elements and facets of the proposed strategy will be implemented - Implementation timeline and methodology of the proposed strategy is similar to the researched strategy OR

Attachment 5b: ______If your implementation will include deviations from the original implementation, please describe deviations and explain why deviations will not impact the level of effectiveness Attachment 3

Attachment 3 Evidence-based Workgroup

Review

Agency Name: ______Strategy Name: ______

Reviewer Name: ______Date of Review: ______

Reviewer Recommendation:

Approve ______

Disapprove ______(attach completed scoring tool & provide description of specific issues below)

Please provide additional feedback addressing both strengths and weaknesses in applicants proposed approach:

Attachment 4

OKLAHOMA NON-MEDICAL USE OF PRESCRIPTION DRUGS MATRIX

Theoretical Framework

Based on the CDC’s public health system, the following components are necessary to fulfill the following 10 Essential Public Health

Services:1

1. Monitor health status to identify and solve community health problems. 2. Diagnose and investigate health problems and health hazards in the community. 3. Inform, educate, and empower people about health issues. 4. Mobilize community partnerships and action to identify and solve health problems. 5. Develop policies and plans that support individual and community health efforts. 6. Enforce laws and regulations that protect health and ensure safety. 7. Link people to needed personal health services and assure the provision of health care when otherwise unavailable. 8. Ensure competent public and personal health care workforces. 9. Evaluate effectiveness, accessibility, and quality of personal and population-based health services. 10. Research for new insights and innovative solutions to health problems.

1. http://www.cdc.gov/nphpsp/essentialServices.html

Attachment 4

NON-MEDICAL USE OF PRESCRIPTION DRUGS

Theoretical Framework

The Oklahoma Partnership for Success project has utilized CDC’s Essential Public Health Services to identify promising strategies for reducing prescription misuse: 3. Inform, educate, and empower people about health issues. 4. Mobilize community partnerships and action to identify and solve health problems. 5. Develop policies and plans that support individual and community health efforts. Prescription Medication Distribution and Storage – Support the development and implementation of standard prescribing practices – Support the development and implementation of standard storage and handling practices of consumer medications in all facilities Prescription Medication Disposal – Establish a system for safe disposal of household medication – Establish a system for safe disposal of consumer medications in all care programs and facilities – Establish a coordinated system for the destruction of drugs in compliance with state and federal environmental regulations

6. Enforce laws and regulations that protect health and ensure safety. - Support the development and implementation of standard drugged driving practices - Support the development and implementation of standard prescription awareness practices

8. Ensure competent public and personal health care workforces. Community Engagement and Education - Harm of prescription misuse (e.g., sharing, self-medicating) - Safe storage - Safe disposal Health Care Engagement and Education - Use of the PMP Law Enforcement-Criminal Justice Engagement and Education - Oklahoma laws concerning prescription medication Attachment 4

NON-MEDICAL USE OF PRESCRIPTION DRUGS: Evidence Based Strategies

DOMAIN: COMMUNITY

RISK / CONTRIBUTING FACTORS STRATEGY REFERENCES STRENGTH Social norms regarding NMUPD Mass media campaigns/advocacy 12 2 10 1 Retail availability Prescription Monitoring Program (PMP) 19 3X Social Prescribing Forms 19 3 Emergency room prescribing Emergency room social prescribing forms 2 2

*Resources numbers are keyed to the attached References List.

** "Strength" refers to rigor, quality of the evidence referenced in the "REFERENCES" column.

Strength Code: 0=Not research; 1=Weak; 2=Moderate; 3=Strong

X = Strategy is ineffective

Oklahoma Department of Mental Health and Substance Abuse Services - Evidence Based Practices Workgroup September 17, 2014

Attachment 4

NON-MEDICAL USE OF PRESCRIPTION DRUGS: Evidence Based Strategies

DOMAIN: SCHOOL

RISK / CONTRIBUTING FACTORS STRATEGY REFERENCES* STRENGTH** Low school involvement & commitment School activities 22 2 9 2 to 3

*References numbers are keyed to the attached References List.

** "Strength" refers to rigor, quality of the evidence referenced in the "REFERENCES" column. Strength Code: 0=Not research; 1=Weak; 2=Moderate; 3=Strong x = Strategy is ineffective

Oklahoma Department of Mental Health and Substance Abuse Services - Evidence Based Practices Workgroup September 17, 2014

Attachment 4

NON-MEDICAL USE OF PRESCRIPTION DRUGS: Evidence Based Strategies

DOMAIN: FAMILY

RISK / CONTRIBUTING FACTORS STRATEGY REFERENCES* STRENGTH** Lack of parental involvement/monitoring Parental training/education 9 3 6 1 "Poor" parenting Parental & family training 24 1 25 2 Parental approval/disapproval of drug use Parental education 24 1 25 2 Parental substance abuse Parental counseling & education 24 1

*References numbers are keyed to the attached References List.

** "Strength" refers to rigor, quality of the evidence referenced in the "RESOURCES" column. Strength Code: 0=Not research; 1=Weak; 2=Moderate; 3=Strong x = Strategy is ineffective

Oklahoma Department of Mental Health and Substance Abuse Services - Evidence Based Practices Workgroup September 17, 2014

Attachment 4

NON-MEDICAL USE OF PRESCRIPTION DRUGS: Evidence Based Strategies

DOMAIN: PEER

RISK / CONTRIBUTING FACTORS STRATEGY REFERENCES* STRENGTH** Peers' misperception of substance use Social norms campaign 13 2 24 2

*References numbers are keyed to the attached References List.

** "Strength" refers to rigor, quality of the evidence referenced in the "REFEERENCES" column. Strength Code: 0=Not research; 1=Weak; 2=Moderate; 3=Strong x = Strategy is ineffective

Oklahoma Department of Mental Health and Substance Abuse Services - Evidence Based Practices Workgroup September 17, 2014

Attachment 4

NON-MEDICAL USE OF PRESCRIPTION DRUGS: Evidence Based Strategies

DOMAIN: INDIVIDUAL

RISK / CONTRIBUTING FACTORS STRATEGY REFERENCES* STRENGTH** Misperception of risk/harm Education 1 2 6 2 21 1 17P 3X 10, 25 3 Media advocacy 1 2 6 2 21 2 Counseling 1 2 6 2 Social norms campaign 20 2 Sensation-seeking personality Counseling 1 2 22 2 Other drug use/abuse Counseling 3 2 Social norms campaign 4, 14 0 5 2 7 1 Antisocial behavior personality disorder Counseling 11 1 *References numbers are keyed to the attached References List. ** "Strength" refers to rigor, quality of the evidence referenced in the "REFEERENCES" column. Strength Code: 0=Not research; 1=Weak; 2=Moderate; 3=Strong X = Strategy is ineffective P = For profit program

Oklahoma Department of Mental Health and Substance Abuse Services - Evidence Based Practices Workgroup September 17, 2014

Attachment 4

NON-MEDICAL USE OF PRESCRIPTION DRUGS: Related Strategies

MULTI-PRONGED PROGRAMS SUGGESTIONS

IF ADDRESSING THIS ISSUE ...... THEN CONSIDER THESE STRATEGIES Prescribing practices Social Prescribing Forms Emergency room social prescribing forms Prescription Monitoring Program Prescriber Education Law Enforcement Education on prescribing laws Safe storage/safe handling Agency Education Programs School Education programs (Drug Free; Life Skills; etc.) Media Advocacy

Safe disposal/safe destruction Agency Education Programs School Education programs (Drug Free; Life Skills; etc.) Media Advocacy Law Enforcement Education on disposal laws Community engagement/education Community mobilization - perception of harm when sharing or taking medicine School Education programs (Drug Free; Life Skills; etc.) not prescribed for you Media Advocacy - drugged driving Law Enforcement Education on prescription laws

September 17, 2014

NON-MEDICAL USE OF PRESCRIPTION DRUGS: Evidence Based Strategies Attachment 4 REFERENCES

1. Arria, A. M., Caldeira, K. M., Vincent, K. B., O'Grady, K. E., & Wish, E. D. (2008). Perceived harmfulness predicts nonmedical use of prescription drugs among college students: interactions with sensation-seeking. Prevention Science, 9(3), 191-201.

2. Baehren, D. F., Marco, C. A., Droz, D. E., Sinha, S., Callan, E. M., & Akpunonu, P. (2010). A Statewide Prescription Monitoring Program Affects Emergency Department Prescribing Behavior. Annals of emergency medicine, 56(1), 19-23.e13.

3. Benotsch, E. G., Koester, S., Luckman, D., Martin, A. M., & Cejka, A. (2011). Non-medical use of pre- scription drugs and sexual risk behavior in young adults. Addictive Behaviors, 36(1-2), 152-155.

4. Blanco, C., Alderson, D., Ogburn, E., Grant, B. F., Nunes, E. V., Hatzenbuehler, M. L., & Hasin, D. S. (2007). Changes in the prevalence of non-medical prescription drug use disorders in the United States: 1991-1992 and 2001-2002. Drug Alcohol Dependency, 90(2-3), 252-260.

5. Catalano, R. F., White, H. R., Fleming, C. B., & Haggerty, K. P. (2011). Is nonmedical prescription opiate use a unique form of illicit drug use? Addictive Behavior, 36(1-2), 79- 86.

6. Collins, D., Abadi, M. H., Johnson, K., Shamblen, S., & Thompson, K. (2001). Non-Medical Use of Pre- scription Drugs Among Youth in an Appalachian Population: Prevalence, Predictors, and Implica- tions for Prevention. Journal of Drug Education, 41(3), 309-326.

7. Daniulaityte, R., Flack, R. S., Wang, J., & Carlson, R. G. (2009). Illicit use of pharmaceutical opioids among polydrug users in Ohio. Addictive Behavior, 34(8), 649-653. Oklahoma Department of Mental Health and Substance Abuse Services - Evidence Based Practices Workgroup September 17, 2014

Attachment 4

NON-MEDICAL USE OF PRESCRIPTION DRUGS: Evidence Based Strategies

REFERENCES

8. Fleary, S. A., Heffer, R. W., & McKyer, E. L. (2011). Dispositional, ecological and biological influences on adolescent tranquilizer, Ritalin, and narcotics misuse. Journal of Adolescence, 34(4), 653-663.

9. Ford, J. A. (2009). Nonmedical Prescription Drug Use Among Adolescents. Youth & Society, 40(3), 336- 352.

10. Gruenewald, P. J., Johnson, K., Shamblen, S. R., Ogilvie, K. A., & Collins, D. (2009). Reducing adoles- cent use of harmful legal products: intermediate effects of a community prevention intervention. Substance Use & Misuse, 44(14), 2080-2098.

11. Hall, M. T., Howard, M. O., & McCabe, S. E. (2010). Subtypes of adolescent sedative/anxiolytic mis- users: A latent profile analysis. Addictive Behavior, 35(10, 882-889.

12. Johnson, E. M., Porucznik, C. A., Anderson J. W., & Rolfs, R. T. (2011). State -Level Strategies for Reducing Prescription Drug Overdose Deaths: Utah's Prescription Safety Program. Pain Medicine, 12, S66-S72.

13. Johnston, L. D., O'Malley, P. M., Bachman, J. G., & Schulenberg, J. E. (2006). Monitoring the Future national survey results on drug use, 1975-2005. Volume I: Secondary school students. NIH Publication No. 06-5883. Bethesda, MD: National Institute on Drug Abuse.

14. Levine, D. A. (2007). "Pharming": the abuse of prescription and over -the -counter drugs in teens. Current Opinion in Pediatrics, 19(3), 270-274.

Oklahoma Department of Mental Health and Substance Abuse Services - Evidence Based Practices Workgroup September 17, 2014

Attachment 4

NON-MEDICAL USE OF PRESCRIPTION DRUGS: Evidence Based Strategies

REFERENCES

15. McCabe, S. E., Cranford, J. A., Morales, M. & Young, A. (2006). Simultaneous and concurrent polydrug use of alcohol and prescription drugs: prevalence, correlates, and consequences. Journal of Studies on Alcohol and Drugs, 67(4), 529-537.

16. McCabe, S. E., Boyd, C.J., & Young, A. (2007). Medical and nonmedical use of prescription drugs among secondary school students. Journal of Adolescent Health, 40(1), 76-83.

17. Osborne, D., & Ross, D. (2006). The Stay on Track program evaluation. Final report of the longitudinal study: Prepared for the National Center for Prevention and Research Solutions.

18. Paulozzi, L. J., Kilbourne, E. M., & Desai, H.A. (2011). Prescription Drug Monitoring Programs and Death Rates from Drug Overdose. Pain Medicine, 12(5), 747-754.

19. Paulozzi, L. J., Weisler, R. H., & Patkar. A. A. (2011). A national epidemic of unintentional prescription opioid overdose deaths: how physicians can help control it. Journal of Clinical Psychiatry, 72(5), 589-592. 20. PDMP Center of Excellence at Brandeis University (2011). Prescription Monitoring Programs: An Effec- tive Tool in Curbing the Prescription Drug Abuse Epidemic: Bureau of Justice Assistance.

21. Quintero, G. Peterson, J., & Uyoung, B. (2006). Exploratory Study of Socio -Cultural Factors Contributing to Prescription Drug Misuse Among College Students. Journal of Drug Issues, 36(4), 903-932.

Oklahoma Department of Mental Health and Substance Abuse Services - Evidence Based Practices Workgroup September 17, 2014

Attachment 4

NON-MEDICAL USE OF PRESCRIPTION DRUGS: Evidence Based Strategies

REFERENCES

22. Schepis, T. S., & Krishnan-Sarin, S. (2008). Characterizing adolescent prescription misusers: a popula- tion-based study. Journal of the American Academy of Child & Adolescent Psychiatry, 47(7), 745-754.

23. Schinke, S. P., Fang, L., & Cole, K. C. (2008). Substance use among early adolescent girls: risk and pro- tective factors. Journal of Adolescent Health, 43(f2), 191-194.

24. Schinke, S. P., Fang, L., & Cole, K. C. (2009). Computer-delivered, parent - involvement intervention to prevent substance use among adolescent girls. Preventive Medicine, 49(5), 429-435.

25. Spoth, R., Trudeau, L., Shin, C., & Redmond, C. (2008). Long-term effects of universal preventive interventions on prescription drug misuse. Addiction, 103(7), 1160- 1168.

26. Twombly, E. C., & Holtz, K. D. (2008). Teens and the misuse of prescriptions drugs: evidence-based recommendations to curb a growing societal problem. The Journal of Primary Prevention, 29 (6), 503-516.

NOTE: Six of the above references are listed by SAMHSA as "Strong," "Moderate," or "Evidence of direct effects" research, but are do not appear in the Matrix because they are repeats, not available, or (mostly) are not research articles.

Oklahoma Department of Mental Health and Substance Abuse Services - Evidence Based Practices Workgroup September 17, 2014

Attachment 5: Budget Summary/Justification

Agency Name: Focus County/Community: Project: SPF-PFS

A. Personnel: An employee of the agency whose work is tied to the proposal. Must include a minimum of one full-time SPF-PFS Coordinator.

Position Name Annual Level of Effort Cost Salary/Rate

TOTAL

JUSTIFICATION: Describe the role and responsibilities of each person.

B. Fringe Benefits: List all components of fringe benefits rate

Component Rate Wage Cost

TOTAL

JUSTIFICATION:

C. Travel: Explain the need for all travel. Must include two-night trips to Oklahoma City for the SPF-PFS Coordinator.

Purpose of Location Item Rate Cost Travel (Ex: Airfare, Lodging, Per Diem, Mileage)

TOTAL

JUSTIFICATION: Describe the purpose of all travel and how costs were determined.

D. Equipment: Item with a unit price of $500.00 or more and a usable life of one year or more.

Item(s) Rate Cost

TOTAL

JUSTIFICATION: Describe the purpose of equipment.

E. Supplies: Materials costing less than $500 per unit and often having one-time use.

Item(s) Rate Cost

TOTAL

JUSTIFICATION: Describe need and include explanation of how costs were determined.

F. Contractual: Expenses paid to non-employee for services or products. All subcontracts require prior approval.

Entity Product/Service Cost

TOTAL

JUSTIFICATION: Explain the need for each agreement and how it relates to the project.

H. Other: Expenses not covered in any of the previous budget categories.

Item(s) Rate Cost

TOTAL

JUSTIFICATION: Describe need and include explanation of how costs were determined.

Indirect cost rate: Indirect costs are limited to 15% of total direct costs.

BUDGET SUMMARY:

Category Request Salaries & Wages Fringe Benefits Travel Equipment Supplies Contractual Other Total Direct Costs Indirect Costs Total Project Costs

ODMHSAS Substance Abuse Prevention Service Regions

CRAIG KAY NOWATA OTTAWA CIMARRON TEXAS BEAVER HARPER WOODS GRANT ALFALFA

OSAGE WASHINGTON

GARFIELD NOBLE Region # PAWNEE ROGERS DELAWARE ELLIS MAJOR MAYES Cherokee Nation Behavioral Health Services WOODWARD 5 TULSA (918) 207-4977 PAYNE CREEK DEWEY CHEROKEE BLAINE KINGFISHER WAGONER LOGAN Eagle Ridge Institute 16 (405) 463-7541 ADAIR CUSTER LINCOLN Muskogee ROGER MILLS OKLAHOMA OKMULGEE Gateway to Prevention and Recovery CANADIAN OKFUSKEE SEQUOYAH 14 (405) 275-3391 CLEVELAND McIntosh WASHITA BECKHAM Neighbors Building Neighborhoods CADDO HASKELL GRADY 15 SEMINOLE Hughes (918) 683-4600 POTTAWATOMIE PITTSBURG KIOWA GREER

McCLAIN LATIMER

OU Southwest Prevention Center LEFLORE 8 (405) 325-4282 COMANCHE GARVIN PONTOTOC

HARMON JACKSON COAL

STEPHENS Northwest Center For Behavioral Health TILLMAN MURRAY 1 PUSHMATAHA (580) 571-3240 COTTON JOHNSTON ATOKA

CARTER OSU Seretean Wellness Center PANOK JEFFERSON McCURTAIN 3 MARSHALL CHOCTAW (405) 624-2220 LOVE BRYAN

OSU Seretean Wellness Center Tri-County Tulsa City-County Health Department 9 (918) 756-1248 17 (918) 595-4274

Preventionworkz Southeastern Oklahoma Interlocal Cooperative 2 (580) 234-1046 6 (580) 286-3344

Red Rock West Neighbors Building Neighborhoods 12 (580) 323-6021 7 (918) 424-6301

Red Rock West: Yukon Satellite Wichita Mountains Prevention Network – Ardmore 13 (405) 354-1928 10 (580) 490-9021

ROCMND Area Youth Services Wichita Mountains Prevention Network – Lawton 4 (918) 256-7518 11 (580) 355-5246

Bid Glossary • RPC: Acronym for Regional Prevention Coordinators. RPCs represents the name used by the ODMHSAS for those agencies providing regional and SPF SIG prevention services. • Baseline: The level of behavior that is recorded before an intervention or service is provided. • Block Grant: Refers to the Substance Abuse Prevention and Treatment Block Grant funding provided by Substance Abuse and Mental Health Services Administration (SAMHSA) for treatment and prevention services. • Capacity: The various types and levels of resources that an organization, collaborative group or coalition has at its disposal to meet the implementation demands of specific interventions. • Capacity Building: Increasing the ability and skills of individuals, groups, and organizations to plan, undertake, and manage initiatives. The approach also enhances the capacity of the individuals, groups, and organizations to deal with future issues or problems. • Coalition: a coalition is defined as a community-based formal arrangement for cooperation and collaboration among groups or sectors of a community in which each group retains its identity, but all agree to work together toward a common goal of building a safe, healthy, and drug-free community. • Community: People with a common interest living in a defined area. For example, a neighborhood, town, part of a county, county, school district, congressional district or regional area. • Community Readiness: is the level of a community’s readiness and capacity to address an issue. To assess a community’s readiness, the ODMHSAS recommends that Suppliers use the Tri-Ethnic Center’s Community ReadinessModel/Tool: http://triethniccenter.colostate.edu/communityReadiness_home.htm • Construct: The conceptual framework used to organize substance consumption and consequence data into discrete categories, or "constructs." • Cultural Competence: Refers to an ability to interact effectively with people of different cultures. Cultural competence is comprised of four components: (a) Awareness of one's own cultural worldview, (b) Attitude towards cultural differences, (c) Knowledge of different cultural practices and worldviews, and (d) Cross-cultural skills. Developing cultural competence results in an ability to understand, communicate with, and effectively interact with people across cultures. • Department: Oklahoma Department of Mental Health and Substance Abuse Services (ODMHSAS). • Disparity Impact Statement: Describes how a Supplier of services will determine who the proposed number of individuals to be served by subpopulations in the grant service area are; how the Supplier will develop a Quality Improvement Plan using available data; and how the Supplier will adhere to the National Standards for Culturally and Linguistically Appropriate Services (CLAS Standards) in Health and Health Care. • Environment: In the Public Health Model, the environment is the context in which the host and the agent exist. The environment creates conditions that increase or decrease the chance that the host will become susceptible and the agent more effective. In the case of substance abuse, the environment is a societal climate that encourages, supports, reinforces, or sustains problematic use of drugs. • Epidemiology Workgroups: For purposes on this contract, these are groups of individuals that collect, analyze, and apply implications from data about alcohol, tobacco and illicit drug-related problems to improve prevention practice. The workgroups bring systematic, analytical thinking to understanding the causes and consequences of the use of alcohol, tobacco and other drugs. • Environmental Strategies: Population level evidence based strategies that establishes or changes community standards, codes, and attitudes and thus reduce the incidence and prevalence of substance abuse. These strategies can center on legal and regulatory issues or can relate to service and action- oriented initiatives. Examples include technical assistance (TA) to communities to maximize enforcement of laws governing availability and distribution of legal drugs, modification of policies and practices, and training of environmental influencers such as beverage servers or health practitioners. • Evaluation: A formalized approach to studying the goals, processes, and outcomes of projects, policies, and programs. Evaluations can involve quantitative methods of social research or qualitative methods or both. • Evidence-Based Practice: An evidence-based practice, also called EBP, refers to approaches to prevention or treatment that are validated by some form of documented research evidence. The ODMHSAS has adopted the following three criteria to define an evidence-based practice - Tier 1: Inclusion in Federal registries of evidence-based interventions; Tier 2: Reported (positive effects on the primary target outcome) in peer-reviewed journals; or Tier 3: Documented effectiveness supported by other sources of information and the consensus judgment of informed experts. • Indicator: For each data construct, one or more specific measures (or “indicators”) are identified. Unlike the underlying constructs, indicators have specific data sources and precise definitions. Indicators are what are used to collect data and quantify the constructs related to outcomes. • Intermediate variables: Also known as intervening variables, are risk or protective factors that have been identified through research as being strongly related to and influencing the occurrence and magnitude of substance use and related risk behaviors and their consequences. These variables are the focus of prevention interventions, changes in which are then expected to affect consumption and consequences. • Needs Assessment: A formal process of collecting and analyzing data to estimate the size, clarify, and nature of drug use/abuse; a second area involves assessing capacity, resources, readiness and gaps in service delivery. In the SPF process, this data is used to estimate the consumption and consequences patterns associated with substance abuse. • ODMHSAS: Acronym for Oklahoma Department of Mental Health and Substance Abuse Services. • Project Site: Refers to the specific geographic location for the population of focus or where the services are provided/targeted. • Public Health Approach: A public health approach focuses on change for entire populations. Population-based public health considers an entire range of factors that determine health. • Region: The geographical unit used by the ODMHSAS to describe the service area for the block grant/state appropriated funded projects. Each region is comprised of one or more counties. There are 17 RPC regions in the state of Oklahoma. See Attachment 6. • SPF: Acronym for Strategic Prevention Framework. The SPF represents a public health framework for preventing substance use and the problems related to it. The model is based on the five steps of assessment, capacity building, planning, implementation of evidence-based practices, and evaluation with two cross-cutting principles of cultural competency and sustainability. • SPF-PFS: Acronym for Strategic Prevention Framework Partnership For Success • SPF SIG: Acronym for Strategic Prevention Framework State Incentive Grant. The SPF SIG is a time-limited prevention project (cooperative agreement) funded by the SAMHSA, CSAP. The purpose of the SPF SIG program is to provide funding to States, Federally recognized Tribes and U.S. Territories to: (1) Prevent the onset and reduce the progression of substance abuse, including childhood and underage drinking; (2) Reduce substance abuse- related problems; and (3) Build prevention capacity and infrastructure at the State, tribal, territorial and community-levels. • Strategic Plan: A comprehensive document that includes a work plan with goals, objectives, measures, and other key project information. A strategic plan may also articulate assessment findings, justification for strategy, plans for sustainability and other key project elements. • Substance Abuse: Substance abuse is the overindulgence in and dependence of a drug or other chemicals including alcohol leading to effects that are detrimental to the individual's physical and mental health, or the welfare of others. The disorder is characterized by a pattern of continued pathological use of a medication, non-medically indicated drug, alcohol, or toxin that results in repeated adverse social consequences related to drug use, such as failure to meet work, family, or school obligations, interpersonal conflicts, or legal problems. • Sustainability: Sustainability in its simplest form describes a characteristic of a process or outcome that can be maintained at a certain level indefinitely. To elaborate further, it is the ability of a program to deliver an appropriate level of benefits for an extended period of time after major financial, managerial, and technical assistance from an external donor is terminated.

• Technical Assistance (TA): Services provided by professional prevention staff intended to provide technical guidance to prevention programs, community organizations, and individuals to conduct, strengthen, or enhance activities that will promote prevention.

Attachment 8: Advancing Environmental Strategies for Alcohol, Tobacco, and Other Drug Prevention

The purpose of this document is to advise Area Prevention Resource Centers on the merits of environmental prevention strategies and in preparation for new federal outcome-based prevention requirements. Environmental prevention approaches, coordinated with effective community education strategies and a strong media advocacy effort, have demonstrated successful outcomes. Consequently, a focus on evidence-based, environmental prevention strategies will position the Oklahoma prevention network to achieve and sustain these outcomes within the communities we serve.

Environmental, Policy-Based Approaches Significant advances have occurred in the field of prevention. New designs in community and school- based prevention approaches have been shown to be far superior to past efforts. Environmental approaches have been shown to affect major positive changes of alcohol, tobacco and other drug (ATOD) problems and have demonstrated the ability to sustain a long-term impact. Environmental approaches in preventing alcohol and other drug problems use a public health model to address the environment where problems occur. The “environment” is defined as the social, legal, economic and cultural context or community conditions in which individuals and alcohol, tobacco, and other drugs come together. Many of these conditions are controlled by public and private policies that affect accessibility to alcohol, tobacco and other drugs, determine the likelihood of using these drugs in high-risk settings, or influence the desirability of using a particular drug. Changing public policy to improve public health and safety requires the development of and advocacy for recommendations to elected officials (usually) who have the authority to implement those policies. Private policies are more directly influenced – to businesses, schools and school districts, organizations and institutions, and families - to improve the health and safety conditions of those entities and the community as a whole. However, public policies, because they are set in place by ordinance, regulation, or statute, have much greater impact and sustaining power.

Effective environmental prevention campaigns incorporate the following components that work together to create a comprehensive strategy. Each component is equally important, so much so, that campaigns that ignore or intentionally skip even one component are far less likely to result in sustainable outcomes. Additionally, the integrated components of an environmental prevention strategy follow the same intuitive process as the five steps of the Substance Abuse and Mental Health Services Administration’s (SAMHSA) Strategic Prevention Framework (SPF), which include assessment, capacity, planning, implementation and evaluation. Following are the components of a comprehensive environmental prevention strategy:

Data Collection/Analysis (SPF: Assessment & Evaluation) Prevention policy interventions based on assumptions or best guesses are ineffective and waste precious, limited resources. Therefore, the importance of collecting and analyzing data before, during, and after an environmental prevention strategy is implemented cannot be overstated. Data informs communities about the type and scope of the problem that exists and helps to identify solutions. Data guides communities through the implementation process, and data demonstrates the change that occurs as a result of the effort. In addition, data gives credibility to our efforts and greatly increases the chances for sustainable outcomes.

Community Organizing (SPF: Capacity and Implementation) Prevention is not and should not be the exclusive realm of trained specialists. Prevention should be driven by the community, with prevention professionals serving as navigator and technician. This means that prevention professionals are responsible for organizing key sectors of the community to define and support the change process. In order for community-level change to occur, the community itself must subscribe to the intent of the change and understand their role in creating and enforcing the change. Strategic partnerships must be developed to ensure the right community network exists to build the capacity needed to support and enforce the policy change. Coalitions, therefore, must represent the community, and the community must be given meaningful roles in the long-term change process.

Policy Development (SPF: Planning and Implementation) Policy interventions are developed based on data as well as community input and community readiness for change. Policies can include institutional policies, public policies, or private policies – any of which seek to create long-term, sustainable community change related to alcohol, tobacco, or other drug norms. Policy development includes the creation of new policies or the enforcement or improvement of existing policies. The role of the prevention professional is to be knowledgeable of evidence-based policy interventions, to review and analyze existing policies to see if they can be improved, and to develop and guide community coalitions through effective policy solutions.

Enforcement (SPF: Planning and Implementation) Community level change through policy cannot occur unless said policies are enforced. Enforcing existing policies and planning for enforcement for new policies is crucial when developing an environmental, policy-based prevention campaign. This means actively collaborating with local law enforcement and adjudication officials to identify enforcement needs and enforcement plans to accompany each policy campaign.

Media Advocacy (SPF: Planning and Implementation) To advance new policies or enforce existing policies, support is required from a wide spectrum of the community. Media advocacy has been demonstrated as the most efficient and effective strategy to accomplish this support. Media advocacy is the strategic use of earned media to advance a social or policy goal. Media advocacy clearly defines the specific policy goals of a prevention campaign and advances them to the public agenda. Following a successful effort in achieving policy implementation, more media advocacy work is required to gain even broader public support and acceptance. That is, the new policy changes must move to become “community norms.” Achieving this acceptance requires that the media strategy that helped to promote the prevention agenda is also used for “norming” the community to the new policies.

Overcoming the Challenge of Implementing Environmental Prevention Strategies In addition to their recognized effectiveness, prevention strategies using environmental, policy-based approaches operate more efficiently than other approaches. Environmental strategies have demonstrated the ability to sustain a lasting impact. In addition, they produce a much larger impact per dollar invested than other approaches. However, there can be considerable public skepticism regarding strategies based on policy approaches. This public skepticism, combined with the tradition of individually-focused strategies can create barriers to implementing environmental strategies with

2 full public support. Furthermore, many prevention practitioners believe environmental strategies are difficult to plan, slow to implement, and lacking in the kind of immediate personal satisfaction experienced from engaging youth in “alternative activities” or lecturing a group of youth or parents on the dangers of substance abuse. It is the task of the prevention experts working with community coalitions to educate coalition members and the community at large on the advantages of this approach and to promote environmentally based strategies as part of a comprehensive approach, favoring environmental strategies over individually focused prevention efforts. Because of the efficiency and effectiveness of this approach, ODMHSAS is committed to advancing environmental prevention principles and strategies. This does not mean individual-level prevention approaches are unallowable. Rather, prevention strategies other than “environmental” should only be used as adjunctive measures that clearly support the primary environmental changes identified by the community.

Equipping Community Prevention Coalitions to Meet the Challenge Environmental prevention strategies that advance public and private policies to change community norms require specific knowledge, specialized skills, careful planning and broad community support. To ensure community coalitions possess this expertise, it is advisable for APRC staff to demonstrate the following minimum skill sets:

1. Community Organizing: • Knowledgeable and competent in organizing, developing and sustaining community-based coalitions aimed at achieving environmental change to prevent and reduce community ATOD problems; • Knowledgeable of the purpose and function of multi-system collaboration to affect organizational and systems changes to prevent and reduce ATOD problems in communities;

2. Policy: • Knowledge of the underlying principles of the public health perception of alcohol, tobacco and/or other drug problems; • Knowledge of the underlying principles and application of environmental strategies that advance policy-based prevention approaches to reduce alcohol, tobacco, and/or other drug problems • Competency to translate community-based planning objectives to prevent and reduce alcohol, tobacco and other drug problems into action plans using environmentally focused strategies with specific policy goals.

3. Media Advocacy: • Knowledge of the underlying principles of the use of media advocacy to prevent and reduce alcohol, tobacco or other drug problems; • Competency in translating community-based planning objectives to prevent and reduce alcohol, tobacco and other drug problems into policy goals for media advocacy; and, • Competency in planning, developing and implementing effective media action plans for alcohol, tobacco and other drug prevention campaigns.

Community-Based Coalitions

3 Individual organizations, institutions and citizens join in collaboration to offer their resources and specialized strengths with others to achieve community change not possible by any single organization. Specialists in community organization and collaborative engagement seek to bring community residents and organizations together to review the strengths and needs in their community and to become planners and advocates for community improvement. This community- based planning recognizes and incorporates a full range of available assets and community resources. Then, within the context of the community-based strategic plans, the key staff professionals described above work as a team to advance environmentally focused prevention strategies based on the priorities and needs developed by the planning group.

The prevention professional’s role in a coalition is to galvanize the community to effective and measurable action, bringing into collaboration a larger, more focused group of community voices, including parents and youth, business owners and managers, health professionals, law enforcement professionals, members of the faith community, and community-based organizations. The primary task of a prevention specialist in a coalition is to advocate for the improvement of community conditions that influence or create alcohol, tobacco, or other drug use/abuse. Environmentally- focused alcohol, tobacco and other drug prevention campaigns should be developed through the community planning process. ODMHSAS sees this funding as being leveraged by other community resources and as providing leverage to additional fund-seeking efforts.

Assisting Community Coalitions To assist community coalitions in focusing their prevention efforts toward environmental approaches, ODMHSAS recommends incorporating the following strategies into planning efforts with community coalitions:

• Combining Research Efforts with Prevention Activities Research institutions, based privately or as part of a university, are constantly seeking opportunities to examine the efficacy of various methods employed in creating community change. Teaming with an evaluator allows a community coalition to have access to advanced tools for implementing effective prevention campaigns and monitoring outcomes.

• Formal Training Building capacity through training opportunities for community coalition members should be part of an overall strategy of a prevention campaign. Training for community coalitions and other key community stakeholders should address the elements of the Strategic Prevention Framework, including community assessment, prevention planning, implementation, and evaluation. Training should consistently focus on the use of evidence-based prevention strategies, including the strategies of environmental prevention (community organizing, media advocacy, data collection, policy development and enforcement). This means APRC staff must remain knowledgeable on the most current prevention research and methods. ODMHSAS encourages APRC staff to utilize the Department’s prevention staff and resources for ongoing technical assistance. In addition, ODMHSAS encourages APRC staff to participate in national professional conferences such as National Prevention Network, OJJDP, and CADCA to ensure Oklahoma’s continued growth toward leadership in the field of prevention.

4 • Mentoring by Skilled Environmental Prevention Practitioners Staff and the coalition members can develop formal mentoring relationships with other experienced practitioners across the prevention network to share ideas, combine resources when needed, and collaborate on common prevention initiatives. Statewide and regional collaborative projects increase efficiency by combining resources and efforts, and increases effectiveness through cooperative planning and shared vision. This level of collaboration can be achieved through formal planning committees on common initiatives or informally with traditional networking methods.

• Establishing Strategic Prevention Partnerships All regions of the state have community-based as well as state organized prevention-oriented collaboratives that already exist. It is vital that APRCs form strategic partnerships with these collaboratives in order to more effectively advance alcohol, tobacco, and other drug prevention goals. Minimally, APRC staff should collaborate with Turning Point Partnerships, Oklahoma Commission on Children and Youth (OCCY), 2Much2Lose, and Students Working Against Tobacco (SWAT) as these entities operate local coalitions in many communities across the state. Locally, APRCs should strategically identify other key community stakeholders that may have influence or decision-making authority to advance alcohol, tobacco, and other drug prevention goals. These include elected officials, law enforcement, youth, parents, residents, school administration, chambers of commerce or business leaders, service organizations, faith leaders, and the like. The role of the APRC is to mobilize these stakeholders and existing collaboratives into action around well-designed prevention campaigns.

5 Strategies and Interventions for Reducing Nonmedical Use of Prescription Drugs: A Review of Literature (2006–2013)

October, 2013 Strategies and Interventions for Reducing Nonmedical Use of Prescription Drugs: A Review of Literature (2006–2013)

October, 2013

!"#$$#%%&%%%%' () Developed under the Substance Abuse and Mental Health Services Administration’s Center for the Application of Prevention Technologies contract (Reference #HHSS277200800004C); and under a subcontract to the Prescription Drug Monitoring Program Center of Excellence, Brandeis University

Developed under the Substance Abuse and Mental Health Services Administration’s Center for the Application of Prevention Technologies contract. Reference #HHSS277200800004C. For training and/or technical assistance use only.

Table of Contents

INTRODUCTION ...... 1

Methods ...... 1

Caveats ...... 1

How to Use These Resources ...... 2

TABLE 1. BRIEF SUMMARIES...... 6

TABLE 2. DETAILED SUMMARIES ...... 14

REFERENCES ...... 31

Developed under the Substance Abuse and Mental Health Services Administration’s Center for the Application of Prevention Technologies contract. Reference #HHSS277200800004C. For training and/or technical assistance use only.

Strategies and Interventions for Reducing Nonmedical Use of Prescription Drugs: A Review of Literature (2006-2013)

INTRODUCTION

Methods Using a social-ecological framework, this document identifies strategies interventions to reduce the nonmedical use of prescription drugs (NMUPD), based on articles published between 2006 and 2013. This range of dates was dictated by available resources and the view that more recent (post-2005) articles would be more relevant for planning current prevention activities. The review focused on United States samples of adolescents and older adults. While all classes of prescription drugs were examined, specific focus was given to opioid/pain relievers—the most common class of prescription drug used for nonmedical purposes.

The literature search was conducted using PSYCHINFO, PUBMED, and EBSCO. Search terms included “prescription drugs,” “opioid,” “opiates,” “sedatives,” “tranquilizers,” and “stimulants,” in combination with: “adolescents,” “older adults,” “elderly,” “consequences,” “risk and protective factors,” “availability,” “access,” “community,” “norms,” “family,” “parental,” “mental health,” “pain,” “chronic pain,” and “school.”

Criteria for including articles included the following:

 The full text was available.  The article was published in a peer-reviewed journal.  The study had clearly identified methodologies and results, or was a well-researched literature review.  At least one of the main findings was specifically related to the non-medical use of prescription drugs.  The study specifically addressed risk and protective factors or, in the case of a literature review, included a section of the review on factors associated with NMUPD.

In addition, all entries included in this literature document were reviewed for clarity by at least two reviewers with post-graduate degrees. Any differences in either the application of the selection criteria or the entries in Table 1 and 2 (described below) were resolved by consensus.

Caveats 1. The findings are limited to the time frame, libraries, and search parameters described above. 2. The body of research on interventions to reduce NMUPD is relatively young and meager. Thus, one or a few studies could dramatically shape our understanding of effective methods to reduce NMUPD. The fact that the effectiveness of a given intervention is not supported by one or more

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well-designed research studies may say less about the promise of that intervention and more about the current paucity of relevant literature. 3. The methodological rigor of the studies reviewed varies widely. For example, some studies used longitudinal designs that followed individual subjects over time, but most used cross- sectional designs that cannot determine whether a causal relationship exists between a risk or protective factor and NMUPD. 4. Most of the studies reviewed (10 of 15) focused on adolescents versus young adults (e.g., college students) or adults.

How to Use These Resources This document included four sections:

1. Introduction 2. Table 1: Brief Summaries 3. Table 2: Detailed Summaries 4. References

There are also two companion documents you should consult. One, mentioned below, deals with the risk and protective factors underlying NMUPDs: Risk and Protective Factors Associated with Nonmedical Use of Prescription Drugs: A Review of Literature (2006-2013). The other is a glossary of terms:VH.J1H:C Glossary of Research Terminology.

Although there are several ways to approach and use these resources, the following are suggested steps or guidelines.

Start with risk and protective factors. While NMUPD may be a serious problem across your state, the factors that drive the problem in different communities may vary considerably. For example, in one community, high school students may have low perceptions of the risks associated with NMUPD. However, this may not be an important risk factor in another community that has a strong and longstanding substance abuse education program that emphasizes the dangers of NMUPD, and a community-wide media campaign that reinforces that message. To be effective, prevention strategies or interventions must be linked to the risk and protective factors that drive the problem in your community. Therefore, it is critical that you begin your search for appropriate prevention strategies with a solid understanding of these factors, based on a comprehensive review of local quantitative and qualitative data.

Once you have identified local risk and protective factors, use the companion review Risk and Protective Factors Associated with Nonmedical Use of Prescription Drugs: A Review of Literature (2006-2013) to determine how well supported they are by research, and to make a final selection about which one or ones to focus on. (The risk and protective factor review contains instructions to guide you through this process.)

Next, use Table 1: Brief Summaries to determine which of the factors you have identified are addressed by the interventions included in this review. Using interventions that have been evaluated (i.e., those

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Page 2 included in this review), even when evidence of their effectiveness is imperfect, is more likely to lead to change in NMUPD than selecting an intervention for which no such evidence exists. To find interventions that address the factor(s) of interest in your community, examine the columns labeled Risk Factor(s) and Protective Factor(s). Scan the entire column since a single factor, like “low perception of risk,” may appear in more than one place. You may also find it helpful to look at the column labeled Domain and search for the domain (Individual, Family, School, Peer Community/Environment) in which the risk/protective factor operates.

When searching for a factor of interest, you may notice that other risk and protective factors appear in the same row in relation to the same single study. This tells you that the intervention being studied may also have had an impact on these linked, or associated, factors. This is important to note, because an Intervention that addresses multiple factors may not only be more cost-effective than an intervention that addresses only one factor, but also increases the chances of having an impact on NMUPD. For example, a single, family-based intervention may address both adolescent psychological risk factors, such as depression, and the protective factor of strengthening parental monitoring and rules against substance use.

What if a risk or protective factor identified in your local needs assessment doesn’t appear in Table 1? This might be due to the way you labeled the factor versus the way it is labeled in the table. The labels used in the Risk Factor(s) and Protective Factor(s) columns reflect the language used in the articles, and so may not correspond exactly to more commonly used “standard” terms (see for example National Research Council and Institute of Medicine, 2009, Preventing mental, emotional, and behavioral disorders among young people: Progress and possibilities. Washington, DC: The National Academies Press). If you are not certain whether language in the table represents the same factor(s) of interest to you, take a look at the entry for the article in Table 2: Detailed Summaries, or, if necessary, try retrieving the original (source) article (the full citation appears in Table 2).

The column labeled Population may help you decide how relevant the intervention is to your local conditions. For example, an intervention that was tested with 5th and 6th grade students may not be relevant if your local needs assessment has determined that high school students are the population to be targeted. On the other hand, you may have to “settle” for an intervention shown to be effective for a population that does not match yours exactly, but which does address the risk or protective factor(s) identified through your local needs assessment (see What if you can’t find an appropriate program? below).

The Outcome Measure(s) column can help you determine which interventions to consider based on the outcomes they address. For example, if a risk factor for NMUPD in your community is “over-prescribing of pain medication”, then the outcome “improved patterns in prescribing pain medication for emergency room patients“ may be of interest to you (see Braehren et al., 2009 in Table 1).

Learn more about the studies that seem relevant Table 2. Detailed Summaries provides more information about each of the articles included in Table 1; it is designed to help you decide which of these interventions (if any) best fits your local conditions. Each entry includes: a full citation, so you can locate the

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Page 3 original article (articles are organized alphabetically by author); the type of intervention (e.g., Project Success, a prevention education program for high risk secondary school students); other (apart from risk and protective factors) independent variables assessed (e.g., age, gender); sample characteristics (e.g., high-risk high school students at one of 14 alternative high schools in Washington); the study design (e.g., random-assignment control study, longitudinal design for two cohorts, survey administered at baseline, program end and one-year follow-up); outcomes measured (e.g., 30-day use of alcohol, marijuana and illegal drugs (including NMUPD); key findings (e.g., students in the control [non-Project Success] group had lower use of illegal drugs, excluding marijuana than those in the intervention group at post-test); and study limitations (e.g., low response rates on provider surveys). Even with the benefit of this more detailed information, consider reading the full text of those articles that seem the most relevant to the risk and/or protective factor(s) on which you plan to focus.

Once you have reviewed the details of the study supporting the intervention(s) in which you are interested, you will need to decide whether the evidence of its effectiveness is sufficient. Determining this is beyond the scope of this document, though some of the issues to consider are discussed in CSAP’s 2009 Identifying and Selecting Evidence-Based Interventions Revised Guidance Document for the Strategic Prevention Framework State Incentive Grant Program. Approaches for weighing the evidence of effectiveness for interventions can also be found in the rating systems used by organizations such as the National Registry of Evidence-based Programs and Practices (http://www.nrepp.samhsa.gov/). However, most prevention practitioners would also benefit from the advice of a researcher, evaluator, or others with appropriate training and experience. Fortunately, in responses to conditions of CSAP-funded initiatives, such as the State Incentive Grant, many states have Evidence Based Workgroups that can help assess the strength of the evidence for an intervention’s effectiveness.

Determine the feasibility of implementation. Once you have identified a strong potential intervention, the next step is to determine how feasible it would be to implement it, given your resources and community conditions (i.e. the community’s willingness and readiness to implement). The processes of assessing feasibility and sources that can help with these processes are discussed in: CSAP’s 2009 Identifying and Selecting Evidence-Based Interventions Revised Guidance Document for the Strategic Prevention Framework State Incentive Grant Program. Additional resources related to feasibility can be found on the CAPT section of SAMHSA’s website

What if you can’t find an appropriate program? Given the small number of interventions identified in this literature review, you may not be able to identify an intervention that meets your needs—that addresses the risk and/protective factors associated with NMUPD in your community, for which there is sufficient evidence of effectiveness, and that is feasible to implement. In this situation, consider searching databases in addition to those searched for this review to retrieve more research articles. Also, consider widening your search to include articles published before and after the time period included in this review, and/or to include articles published in non-refereed journals, many of which use methods as rigorous as articles found in peer-reviewed journals, or to include articles for which the full-text was not available. Or simply try using more search terms.

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Another way to identify a wider range of intervention “possibilities” is to consider interventions that rigorous studies show can influence your risk and protective factors of interest, but which do not provide evidence about outcomes related to NMUPD (or for your targeted population). For example, well- designed evaluations of a number of curriculum-based prevention programs have shown reductions in alcohol and other substance abuse among high school students, but have not specifically measured the effects on NMUPD. Before implementing this sort of program, however, consider whether it may need to be adapted to more specifically address NMUPD. For example, information and exercises on refusal skills might need to be altered to incorporate prescriptions drugs. Also keep in mind that an intervention that lacks evidence of effectiveness for NMUPD, even if it is adapted, may fail to impact NMUPD. Given this, your attempt at repurposing the intervention should be carefully evaluated.

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TABLE 1. BRIEF SUMMARIES

Domain Risk Factor(s) Protective Factor(s) Type of Intervention Outcome Measure(s) Population Source (Individual, Family, School, Peer, and Community/Environment)

Community Unsafe prescribing Not applicable 46 face-to-face presentations of (1) Confidence in 581 physicians attended Cochella and Bateman, 2011. practices of opioid six recommended prescribing prescribing practices; presentations; follow-up prescription drugs practices to health care workers (2) degree to which surveys post intervention; throughout Utah providers had adopted baseline (n= 366), 1 the six recommended month (n=82), 6 month practices; (3) other (n=29) behavior change in opioid- related practices

Community/Environment Over-prescribing pain Use of narcotic registry and PDMP data use by prescribers Patterns of prescribing 18 prescribers of 199 Baehren, et al., 2009. medication Prescription Drug (doctors and health care pain medication for emergency department Monitoring Program professionals) emergency room patients with painful (PDMP) by prescribers patients conditions

Community/Environment None discussed Knowledge of potential Utah Department of Health (1) Public awareness, Utah residents aged 18 Johnson, et al., 2011. dangers of prescription Prescription Pain Medication opinions, and behaviors and older; pre-campaign pain medication Program’s two intervention related to prescription n=413, post-campaign strategies were: (1) statewide drug behaviors; (2) n=410 media campaign targeting adults prescription drug ages 25-54, including its “Use mortality Only As Directed” website; (2) clinical educational materials, including development and distribution of opioid-prescribing guidelines, bookmarks, patient information cards, and posters

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Domain Risk Factor(s) Protective Factor(s) Type of Intervention Outcome Measure(s) Population Source (Individual, Family, School, Peer, and Community/Environment)

Community/Environment None discussed None discussed Multi-stage community (1) Community Four participating Ogilvie, et al., 2008. mobilization strategy to engage readiness; and (2) communities typical of community leaders, retailers, dimension readiness regional centers in rural parents, and school personnel in Alaska; populations range preventing youth use of inhalants from about 3,000 to 9,000; and other harmful legal products two of the in rural Alaska communities have a majority Alaska Native population; others have ’ populations that are over 20% Alaska Native

Community/Environment None discussed; reviewers None discussed State prescription drug monitoring The effects of PDMPs 51 jurisdictions (50 states Paulozzi, et al., 2011. infer over- and/or programs (PDMPs) over time on: (1) drug and Washington DC) inappropriate- prescribing overdose mortality; (2) and doctor-shopping opioid overdose-related mortality; and (3) morphine milligram equivalents

Community/Environment None discussed None discussed Prescription drug misuse A three-fold Two focus groups with Twombly, et al., 2011. prevention message strategies categorization (highly eight seventh graders and resonant, moderately eight eighth graders in the resonant, or not Atlanta metropolitan area resonant) which define in March 2009; no racial, the extent to which a gender, or other student reports that a demographic information message may influence about the participants or him/her and peers to their school is provided, refrain from misusing nor do authors indicate prescription drugs how the sample was recruited

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Domain Risk Factor(s) Protective Factor(s) Type of Intervention Outcome Measure(s) Population Source (Individual, Family, School, Peer, and Community/Environment)

Community/Environment, (1) Peer group approval Not applicable Think Smart curriculum in fifth and (1) Cognitive and social- Fifth-, sixth-, and sevent- Gruenewald, et al., 2009. (See Individual and use; (2) Lifetime sixth grade health classes has two behavioral grade students in all also Johnson, et al., 2009, substance use components: (1) environmental characteristics of schools in all three rural Johnson, et al., 2007, and strategy to reduce access to students related to HLP Alaskan communities; Ogilvie, et al., 2008, below). harmful legal products (HLP)s, use; (2) perceived pretest n=336, posttest including legal prescription, non- availability of HLPs from n=286 prescription and over-the-counter several environmental drugs, as well as household sources products found at home, in schools, and from retail outlets; and (2) school-based curriculum intended to enhance knowledge about HLP use and problems and improve refusal skills and assertiveness

Community/Environment Availability of harmful but (1) Rules and regulations in Comprehensive community-based Availability and attitudes Four Alaska communities Johnson, et al., 2007. (See and School- based legal products businesses, homes, and prevention intervention, including: of legal but harmful with populations ranging also Gruenewald, et al., 2009, schools; (2) anti-drug (1) community mobilization; (2) products and from 3,500 to 9,000 and Johnson, et al., 2009 norms in community, retail strategies, home strategies, substances in four above; and Ogilvie, et al., 2008 family, school; and (3) and school environmental communities below). social influence, life skills, strategies; and (3) school-based and cultural identity prevention education with Think Smart curriculum to address risk factors, social influences, intrapersonal factors, and cultural competence

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Domain Risk Factor(s) Protective Factor(s) Type of Intervention Outcome Measure(s) Population Source (Individual, Family, School, Peer, and Community/Environment)

Family, School Past use of alcohol, Family and school Three studies tested different Prescription drug Middle school students Spoth, et al., 2013. cigarettes, or marijuana at environments, and youth universal interventions (none misuse was assessed from rural communities in baseline competencies targeted prescription drug use using questions about Iowa and Pennsylvania specifically): Study 1 looked at lifetime use of participating in three family-based interventions and barbiturates, studies: Study 1: 446 assigned participating schools to tranquilizers, families of sixth graders; either (a) Preparing for the Drug amphetamines, and/or Study 2: 226 families of Free Years (PDFY), which narcotics. seventh graders from 24 emphasizes adolescent refusal schools; Study 3: Two skills, (b) the Iowa Strengthening consecutive cohorts of Families Program (ISFP), which sixth graders and families strengthens family protective (n=1064 families) from 28 factors, or (c) a control group. school districts. Study 2 assigned participating schools to either (a) a multi- component family- and school- based intervention that combined the ISFP and Life Skills Training (LST) in school and families; (b) a school-only LST intervention group, or (c) a control group. Study 3 assigned participating schools to either (a) PROmoting School-community-university Partnerships to Enhance Resilience (PROSPER) model, which links community teams, public schools, and Cooperative Education System of land-grant universities to implement the ISFP curriculum, or (b) a control group.

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Domain Risk Factor(s) Protective Factor(s) Type of Intervention Outcome Measure(s) Population Source (Individual, Family, School, Peer, and Community/Environment)

Individual (1) Behavioral problems; Not applicable Project Success, a prevention 30-day use of alcohol, High-risk high school Clark, et al. 2010. (2) past 30-days use of education program for high-risk marijuana and illegal students at one of 14 alcohol, marijuana and secondary school students drugs (including alternative high schools in illegal drugs, including NMUPD) Washington NMUPD

Individual College students with (a) Perceived harmfulness of A mock study was used as a (1) Past 6-month College students (n=96) Looby, De Young and involvement in a fraternity stimulant use means for intervening with college nonmedical prescription without any lifetime use of Earleywine, 2013 (in press). or sorority; (b) grade point students; participants received a stimulant use including: prescription stimulant average below 3.5; (c) placebo that they were told was (a) incidence, (b) medication and at least binge drinking in the past 2 methylphenidate and asked to frequency, (c) specific two relevant risk factors weeks; (d) past-month complete tasks and then assess drug used, (d) cannabis use their mood and cognitive abilities; motivations for use; and in second visit, participants were (2) prescription told about the placebo and stimulant-related effects informed of risks of drug use; of expectations effect on drug use over six-months was assessed

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Domain Risk Factor(s) Protective Factor(s) Type of Intervention Outcome Measure(s) Population Source (Individual, Family, School, Peer, and Community/Environment)

Individual, Family Peer and psychological (1) Close maternal Family-oriented, web-based (1) Alcohol use; (2) 108 Asian American Fang, Schinke and Cole, 2010. risks (depression and low relationship, (2) parental substance use prevention cigarette use; (3) mother/daughter (mean self-efficacy) monitoring and rules program with interactive exercises marijuana use; (4) age 13) dyads; control against substance use that require the joint participation NMUPD in past 30 group n=50; intervention of mothers and daughters days; (5) intention to group n=54 use substances in future

Individual, Family None discussed Close maternal Computer-delivered program for (1) Substance use; and Adolescent girls (ages 11- Schinke, Fang, and Cole, relationship, parental mother/daughter dyads to prevent (2) risk and protective 13) and their mother 2009. monitoring, and rules substance use among adolescent factors dyads from greater New against substance use girls York City area (n=916)

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Domain Risk Factor(s) Protective Factor(s) Type of Intervention Outcome Measure(s) Population Source (Individual, Family, School, Peer, and Community/Environment)

Individual, Family, School Use of gateway drugs Family and school Study 1 was a family-focused Self reports of lifetime Rural Iowa communities Spoth, et al., 2008. (alcohol, cigarettes, or environments, and youth intervention assigned participating and past-year with mostly White, middle- marijuana) at baseline competencies schools to either (a) Preparing for prescription drug income, middle school the Drug Free Years (PDFY), misuse students. Study 1 began which emphasizes adolescent in 1993, with 667 sixth- refusal skills, (b) the Iowa graders and families. Strengthening Families Program Study 2 began in 1998 (ISFP), which strengthens family with seventh-graders and protective factors, or (c) a control families. group. Study 2 assigned participating schools to either (a) a multi-component family- and school- based intervention that combined the ISFP and Life Skills Training (LST) in school and families; (b) a school-only LST intervention group, or (c) a control group.

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Domain Risk Factor(s) Protective Factor(s) Type of Intervention Outcome Measure(s) Population Source (Individual, Family, School, Peer, and Community/Environment)

Individual, School, Peer, (1) Peer use of harmful (1) Refusal skills; (2) Think Smart, designed to reduce (1) Past 30-day HLP Program administered in Johnson, et al., 2009. (See Community/Environment legal products (HLP)s; (2) knowledge of drug-related use of HLPs, including legal use of (a) inhalants; (b) classroom settings in 14 also Johnson, et al., 2007, peer normative beliefs consequences; (3) prescription, non-prescription, and prescription medicine; Alaskan frontier Ogilvie, et al., 2008 below; and about HLPs assertiveness skills; (4) over-the-counter drugs as well as (c) over-the-counter communities to a mixture Gruenewald, et al., 2009 cultural identity household products found at medications; and (d) of white and Alaskan above). home, in schools, and from retail common household Native fifth and sixth outlets among fifth- and sixth- products, and/or other grade students grade students in frontier Alaska; drug use (tobacco, curriculum targets six risk and alcohol, and marijuana protective factors or hashish)

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TABLE 2. DETAILED SUMMARIES

Author(s), Article Domain Risk Protective Type of Intervention Other Sample Study Design Outcomes Key Finding(s) Study Limitations title (Individual, Family, Factor(s) Factor(s) Independent Characteristics (Instrument and Measure(s) School, Peer, and Variable(s) (Target Time Frame) Community/ Population) Environment) Baehren, David F., Community/ Over- Use of Prescription Drug Patient age, 18 prescribers of Quasi-experimental, Patterns of High numbers of (1) Study completed Marco, Catherine Environment prescribing narcotic Monitoring Program ethnicity, gender, 199 emergency surveys of prescribers prescribing narcotics at a single A., Droz, Danna E., pain registry and (PDMP) data use by insurance status, department before and after pain prescribed. institution; (2) few Sinha, Sameer, medication PDMP by prescribers (doctors employment, and patients with reviewing Ohio medication for Physicians and uneven practice Callan, Megan, prescribers and health care chief complaint painful conditions Automated Rx emergency changed their of prescribers (4 Akpunonu, Peter. professionals) Reporting System room patients opioid treated 63% of (2009). A statewide (OARRS) data and prescription- patients in study); prescription prescribing (or not) to writing behavior in (3) possible monitoring program patient 41% of Hawthorne effect affects emergency prescriptions. (people alter their department Specifically, they behavior due to an prescribing changed the awareness of being behaviors. Annals number of studied). of Emergency prescriptions per Medicine, 51(1), patient after 19-23. reviewing OARRS data, resulting in fewer or no opioid medicines prescribed in 61% of prescriptions over a one year period.

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Author(s), Article Domain Risk Protective Type of Intervention Other Sample Study Design Outcomes Key Finding(s) Study Limitations title (Individual, Family, Factor(s) Factor(s) Independent Characteristics (Instrument and Measure(s) School, Peer, and Variable(s) (Target Time Frame) Community/ Population) Environment) Clark, Heddy Individual Behavioral None Project Success, a Age, gender, High-risk high Random-assignment 30-day use of Students in the (1) Power of sample Kovach, Ringwalt, problems; discussed prevention education race, and school students control study; alcohol, control (non- was small; (2) Chris L., Hanley, past 30-day program for high-risk ethnicity; school at one of 14 longitudinal design for marijuana and Project Success) program Sean, Shamblen, use of secondary school (urban) and alternative high two cohorts; survey illegal drugs group had lower participation rates Stephen R., alcohol, students percentage of schools in administered at (including use of illegal were low compared Flewelling, Robert marijuana, students in school Washington baseline, program NMUPD) drugs, excluding to other studies of L., Hano, Mary C. and illegal receiving end, and one-year marijuana, than Project Success; (3) (2010) Project drugs, free/reduced follow-up; those in the implementation SUCCESS' effects including lunch hierarchical linear intervention group challenges on the substance NMUPD modeling was the at post-test. The use of alternative primary analysis effect did not high school persist at follow- students. Addictive up. Behaviors, 35, 209–217.

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Author(s), Article Domain Risk Protective Type of Intervention Other Sample Study Design Outcomes Key Finding(s) Study Limitations title (Individual, Family, Factor(s) Factor(s) Independent Characteristics (Instrument and Measure(s) School, Peer, and Variable(s) (Target Time Frame) Community/ Population) Environment) Cochella, Susan, Community Unsafe None 46 face-to-face Not applicable 581 physicians One-hour (1) Confidence (1) The number of (1) Other efforts Bateman, Kim. prescribing discussed presentations attended presentation; three in prescribing unintentional aimed at decreasing (2011) Provider practices of highlighting six presentations: survey administration practices; (2) overdose deaths opioid-related detailing: An opioid recommended follow-up surveys periods [baseline, 1- degree to in Utah involving deaths were intervention to prescription prescribing practices post intervention: month, and 6-months which prescription opioid implemented decrease drugs were presented to baseline (n=366), post presentation providers had medications simultaneously and prescription opioid health care workers 1 month (n=82), (August of 2008 and adopted the six dropped 14% in could be responsible deaths in Utah. throughout Utah; clinic- 6 month (n=29) October of 2009). recommended 2008 from 2007; for the improvement Pain Medicine, 12, based presentations practices; (3) (2) overall, 60– in the number of S73–S76. including use of other behavior 80% of deaths; (2) lack of prescription database change in respondents ongoing funding in opioid-related reported avoiding that the intervention practices prescribing long- was supported by a acting opioids for one-time state grant; acute pain, or with and (3) low sleep aids or response rates on benzodiazepines; provider surveys. (3) providers who participated in the project reported improvements in their prescribing behaviors and increased confidence in their ability to describe the epidemic and safe prescribing behaviors

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Author(s), Article Domain Risk Protective Type of Intervention Other Sample Study Design Outcomes Key Finding(s) Study Limitations title (Individual, Family, Factor(s) Factor(s) Independent Characteristics (Instrument and Measure(s) School, Peer, and Variable(s) (Target Time Frame) Community/ Population) Environment) Fang, Lin, Schinke, Individual, Family Peer and Close Nine-session (45 (1) Alcohol use; 108 Asian September and (1) Alcohol Participants in a (1) Intervention Steven P., Cole, psychological maternal minutes each) Web- (2) cigarette use; American December 2007; use; (2) family-oriented, program was Kristin C.A. (2010) risks relationship; based substance use (3) marijuana mother/daughter randomized control cigarette use; Web-based delivered in English Preventing (depression parental prevention program use; (4) NMUPD; dyads; control trial; pretest and (3) marijuana substance use and was substance use and low self- monitoring; delivered via voiceover (5) depression; group n=50, posttest use; (4) prevention inaccessible to non- among early efficacy) rules against narration, animated (6) self-efficacy; intervention measurements; NMUPD; (5) program at English speaking Asian–American substance use graphics, and games; (7) refusal skills; group n=54; girls’ Intervention groups intention to use posttest showed participants; (2) adolescent session content (8) mother/ age: control completed a 9-session substances in less depressed participating girls: Initial includes skill daughter group 13.25 Web-based substance future mood, and mother/daughter evaluation of a demonstrations and closeness; (9) years, use prevention improved self- dyads were required Web-based, interactive exercises mother/daughter intervention program; generalized efficacy and to have computer mother–daughter that require the joint communication; 12.99 years; estimating equations refusal skills; had access at home; (3) program. Journal of participation of mothers (10) maternal mothers’ age: higher levels of online recruitment; Adolescent Health, and daughters; monitoring; (11) control 41.06 mother-daughter (4) program content 47, 529–532. mother/daughter dyads family rules years, closeness, was not designed were asked to complete against intervention mother-daughter expressly for Asian one session per week substance use; 39.42 years. communication, Americans and (12) intention to and maternal lacked cultural use substances in monitoring, and specificity future reported more family rules against substance use compared to comparison group. They also reported fewer instances of alcohol, marijuana, and illicit prescription drug use in past 30 days and expressed lower intentions to use substances in the future.

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Author(s), Article Domain Risk Protective Type of Intervention Other Sample Study Design Outcomes Key Finding(s) Study Limitations title (Individual, Family, Factor(s) Factor(s) Independent Characteristics (Instrument and Measure(s) School, Peer, and Variable(s) (Target Time Frame) Community/ Population) Environment) Gruenewald, Paul Community/ (1) Peer Lack of ThinkSmart: 15 (1) Intent to use Fifth, sixth, and Pretest- post-test (1) Cognitive An effective (1) No comparison J., Johnson, Environment, group availability sessions taught as and use of HLPs; seventh grade design; fifth, sixth, and and social- community group used; (2) only Knowlton, School. approval and among peers; weekly one-hour (2) cognitive and students in all seventh grade behavioral prevention model assessed three rural Shamblen, Steven use; (2) lack of formal sessions or bi-weekly social-behavioral schools in all students in all schools characteristics for the reduction Alaskan R., Ogilvie, Kristen Lifetime availability in 30- minute sessions in measures [(a) three rural in all three rural of students of HLP use communities; (3) A., Collins, David. substance retail fifth and sixth grade knowledge of Alaskan Alaskan communities; related to HLP incorporates doesn’t differentiate (2009). Reducing use establishment; health classes. Think HLPs use and communities; Pretest surveys given use; (2) environmental between outcomes adolescent use of refusal skills Smart has two primary consequences, Pre-test n=336, in classrooms in each perceived strategies to for prescription harmful legal for teens components: (1) (b) refusal skills, post-test n=286 school, the ES and availability of reduce supply of drugs versus other products: environmental strategy (c) assertiveness, ThinkSmart HLPs from HLPs in HLPs Intermediate effects (ES) to reduce access (d), Native interventions were several combination with a of a community to reduce access to Alaskan cultural fielded, then a environmental cognitive- prevention harmful legal products identify, (e) peer posttest was given sources behavioral life intervention. (HLPs), including legal normative beliefs, one year later; skills curriculum Substance Use prescription, non- (f) peer use] Hierarchical that focuses on Misuse, 44(14), prescription, and over- Generalized Linear demand reduction. 2080–2098. the-counter drugs as Models and Evidence was well as household Hierarchical Linear found for products found at Models used to significant home, in schools, and analyze data increases in from retail outlets; and knowledge about (2) school-based HLP use and curriculum intended to risks, and enhance knowledge decreases in about HLP use and perceived problems, and to availability of HLP improve refusal skills products in the and assertiveness. home and at school. These effects were differentiated across grade groups, reflecting differential exposure to the ThinkSmart program.

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Author(s), Article Domain Risk Protective Type of Intervention Other Sample Study Design Outcomes Key Finding(s) Study Limitations title (Individual, Family, Factor(s) Factor(s) Independent Characteristics (Instrument and Measure(s) School, Peer, and Variable(s) (Target Time Frame) Community/ Population) Environment) Johnson, Erin M., Community/ Non Knowledge of Utah has used a Not applicable Utah residents Random (1) Public The state-funded (1) Program Porucznik, Environment Applicable potential multipronged approach aged 18 and pretest/posttest awareness, educational interventions lacked Christina A., dangers of to address problems older [pre- design; two opinions, and campaign may a method to Anderson, prescription related to prescription campaign telephone-based behaviors have contributed demonstrate a Jonathan W., pain opioid use by educating (n = 413) and public opinion related to to a reduction in causal linkage Rolfs, Robert T. medication providers, patients, and post-campaign surveys: (1) pre- prescription overdose deaths. between the (2011) State-level the general public to (n = 410)] campaign survey drug Collaboration program and strategies for increase knowledge of (baseline data, guided behaviors; (2) among state improvements in reducing the potential dangers of development of prescription agencies are public health; (2) a prescription drug prescription pain program goals, and drug mortality important aspects lack of monitoring or overdose deaths: medication. The Utah campaign materials), of a successful evaluation Utah’s prescription Department of Health’s and (2) post-campaign prevention framework to assess safety program. Prescription Pain survey to evaluate any campaign. Other program impact Pain Medicine, 12, Medication Program changes in public findings: 52% of meant that S66–S72. includes two awareness, opinions, respondents said outcomes were intervention strategies: and behaviors related media messages reported based on (1) a statewide media to prescription pain made them less descriptions; (3) campaign targeting medications). likely to share duration of the adults ages 25- 54, February 2008-May their prescription program was including its “Use Only 2009. Responses medications; 51% insufficient to As Directed” website; from identical said that media monitor output or and (2) clinical questions on the pre- messages made consequences to educational materials, and post- campaign them less likely to establish any including the were compared using take prescription longitudinal trends. development and tests of proportions. medications not distribution of opioid prescribed to prescribing guidelines, them; and 29% bookmarks, patient reported an information cards, and increased posters. understanding of the dangers of prescription pain medication during the past year.

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Author(s), Article Domain Risk Protective Type of Intervention Other Sample Study Design Outcomes Key Finding(s) Study Limitations title (Individual, Family, Factor(s) Factor(s) Independent Characteristics (Instrument and Measure(s) School, Peer, and Variable(s) (Target Time Frame) Community/ Population) Environment) Johnson, Knowlton Individual, School, (1) Peer use (1) Refusal ThinkSmart, designed (1) School Student survey A two-group, Past 30-day Think Smart (1) Unmeasured risk W., Shamblen, Peer, Community/ of HLPs; (2) skills; (2) to reduce use of characteristics; administered in a randomized, matched- HLPs use of curriculum and protective Stephen R., Ogilvi, Environment peer knowledge of harmful legal products (2) community classroom setting control trial with (a) inhalants, significantly factors may have Kristen A., Collins, normative drug-related (HLPs, such as characteristics; in14 nested repeated (b) prescription reduced use of mediated Think David, Saylor, beliefs about consequence; inhalants and over-the- (3) student communities; measures of youth medicine, (c) harmful legal Smart curriculum Brian. (2009). HLPs (3) counter drugs), alcohol, characteristics; student (fifth and sixth over-the- products, effects on HLPs and Preventing youths’ assertiveness tobacco, and other (4) school participation: grades); three waves counter including legal other drug use use of inhalants skills; (4) drugs among fifth- and dynamics Wave 1=460, of data collection: (1) medications, prescription, non- among youth in the and other harmful cultural sixth-grade students in Wave 2= 401, collected prior to and (d) prescription and study communities; legal products in identity frontier Alaska. The Wave 3= 428 Think Smart common over-the-counter (limited frontier Alaskan curriculum consisted of implementation, (2) household drugs as well as generalizability— communities: A 12 core sessions and 3 survey post booster products, household findings based on randomized trial. booster sessions session, and (3) 6- and/or other products found at sample of Alaskan Prevention administered 2- 3 month follow-up drug use home, in schools, native fifth and sixth Science, 10, 298– months later. survey. October 2006- (tobacco, and from retail grade students) 312. ThinkSmart targets six May 2007. alcohol, and outlets, at six risk and protective marijuana or month factors: (1) refusal hashish). assessment after skills, (2) peer use of completing the HLPs, (3) peer curriculum; normative beliefs about inhalant use HLPs, (4) knowledge of reduction was drug-related most prevalent. consequences, (5) This curriculum, assertiveness skills, (6) however, did not cultural identity directly impact youths’ use of tobacco, alcohol, and marijuana. The risk and protective factors measured did not mediate Think Smart effects on reduced substance use among youth.

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Author(s), Article Domain Risk Protective Type of Intervention Other Sample Study Design Outcomes Key Finding(s) Study Limitations title (Individual, Family, Factor(s) Factor(s) Independent Characteristics (Instrument and Measure(s) School, Peer, and Variable(s) (Target Time Frame) Community/ Population) Environment) Johnson, Knowlton, Community/ Availability of (1) Rules and Comprehensive Four Alaska Pre- and post-studies Availability and Developing a Study is primarily Holder, Harold, Environment and harmful but regulations in community-based communities with of each intervention attitudes of community-wide descriptive of Ogilvie, Kristen, School- based legal products businesses, prevention intervention populations strategy; mobilization legal but community intervention rather Collins, David, including homes, and including: (1) ranging from was assessed through harmful prevention is than an empirical Courser, Matthew, prescription schools; (2) community mobilization 3,500 to 9,000 in-person interviews products and feasible in test of the Miller, Brenda, drugs anti-drug (readiness assessment, pre and post; retail substances in Alaskan intervention Moore, Roland, norms in building and expanding strategies tested using four communities Saltz, Bob. (2007). community, base, developing and pre- and post- youth communities A community family, school; implementing a plan of purchase attempts at prevention (3) social action and seeking retail stores; home intervention to influence, life feedback, strategy assessed reduce youth from skills, and dissemination and with post surveys of inhaling and cultural sustaining efforts; (2) attendees at a family ingesting harmful identity environmental night; and pretest and legal products. strategies including posttest surveys of Journal of Drug retail strategies, home teachers/staff Education, 37(3), strategies, and school assessed the school 227-247. environmental environment. Think strategies; and (3) Smart curriculum was school-based assessed through pre- prevention education, and post-observer including the Think reports and student Smart curriculum, to surveys of fifth and address risk factors, sixth grade students social influences, (number and intrapersonal factors, demographics not and cultural presented) competence

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Author(s), Article Domain Risk Protective Type of Intervention Other Sample Study Design Outcomes Key Finding(s) Study Limitations title (Individual, Family, Factor(s) Factor(s) Independent Characteristics (Instrument and Measure(s) School, Peer, and Variable(s) (Target Time Frame) Community/ Population) Environment) Looby, Alison, De Individual College Perceived A mock study was used (1) 96 at-risk, Study examined the (1) Past 6- The expectancy (1) Use of Young, Kyle P., students with harmfulness as a means of Demographics, stimulant-naïve efficacy of a month challenge homogeneous Earleywine, Mitch. (a) of stimulant intervening with college [(a) gender, (b) college students randomized controlled nonmedical successfully sample (at-risk (2013, in press). involvement use students. Participants age, (c ) years of [Eligibility: expectancy challenge prescription modified college students); Challenging in a fraternity received a placebo that education, (d) between 18-25 intervention to prevent stimulant use expectancies (2) short study expectancies to or sorority, (b) they were told was grade point years, current nonmedical including: (a) related to timeframe (6 prevent nonmedical grade point methylphenidate and average, (e) enrollment in prescription stimulant incidence, (b) prescription months) prescription average asked to complete ethnicity, (f) college, lifetime use; randomized frequency, (c ) stimulant effects. stimulant use: A below 3.5, (c) tasks and then assess Greek (fraternity/ nonuse of any control trial specific drug Nevertheless, this randomized, binge drinking their mood and sorority) prescription [intervention (n=47)]; used, (d) intervention group controlled trial. in the past cognitive abilities. involvement]; (2) stimulant three sessions (2 motivations for and a control Drug Alcohol two weeks, During a second visit, expectancies [(a) medication and laboratory visits and 1 use; and (2) group showed Dependence, 132, (d) past- the participants were cognitive at least two online follow-up); all prescription comparable rates 362-268. month told about the placebo enhancement, (b) relevant risk participants completed stimulant- of nonmedical cannabis use and given a broad anxiety and factors: (a) the Prescription related prescription use at didactic lecture and arousal, (c) social involvement in a Stimulant Expectancy expectancy 6-month follow-up. discussion on enhancement, (d) fraternity or Questionnaire-II effects However, negative expectancy effects and guilt and sorority, (b) (PSEQ-II, 45-item expectancies were informed about the dependence]; grade point measure that significant risks of drug use. The substance use: average below assesses prescription predictors of effect on drug use over [(a) binge 3.5, (c) binge stimulant expectancy reduced odds of six-months was drinking, (b) drinking in the effects) at baseline; future use. assessed. alcohol abuse past 2 weeks, (d) participants and dependence, past-month randomized to an (c) marijuana cannabis use. expectancy challenge abuse and The average (EC) or a control dependence] years of condition; all education was participants were 13.49, race/ contacted by email 6 ethnicity was months after their Caucasian second visit and (71%), African asked to complete an American (8%), online survey Hispanic (8%), regarding NPS over Asian (4%), the past 6 months; mixed race (4%), linear mixed-effects and Native modeling American (1%). Developed under the Substance Abuse and Mental Health Services Administration’s Center for the Application of Prevention Technologies contract. Reference #HHSS277200800004C. For training and/or technical assistance use only.

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Author(s), Article Domain Risk Protective Type of Intervention Other Sample Study Design Outcomes Key Finding(s) Study Limitations title (Individual, Family, Factor(s) Factor(s) Independent Characteristics (Instrument and Measure(s) School, Peer, and Variable(s) (Target Time Frame) Community/ Population) Environment) Ogilvie, Kristen A., Community/ None None Assessing community Not applicable Four participating Used a modified CRM (1) Community The Community (1) No control Moore, Roland S., Environment discussed discussed mobilization using the communities assessment tool; 32 readiness; (2) Readiness Model group(s) were used; Ogilvie, Diane C., Community Readiness typical of regional baseline (February dimension proved a useful (2) only four rural Johnson, Knowlton Model (CRM) as part centers in rural and March 2005) and readiness tool in the Alaska Alaskan W., Collins, David of a multi-stage Alaska; 34 post intervention Harmful Legal communities were A., Shamblen, community mobilization populations (October 2006); Products (HLP) assessed; (3) Stephen R. (2008) strategy to engage range from about community readiness prevention study. outcomes for Changing community leaders, 3,000 to 9,000p assessment This short-term substance use were community retailers, parents, two interviews with key feasibility study not assessed readiness to and school personnel in communities informants in four rural demonstrated the prevent the abuse preventing youth use of have a majority Alaskan communities potential value of of Inhalants And inhalants and other Alaska Native 20 months after a CRM as an other harmful legal harmful legal products population, the community integral part of a products In Alaska. in rural other mobilization community Journal of Alaska communities’ strategy had been mobilization Community Health, populations are implemented; strategy for 33(4), 248–258. over 20% Alaska interviews were coded prevention, as a Native and analyzed using guide for the CRM methods intervention in a to yield readiness multi-community scores; aggregate research study, results were analyzed and as a mode of using hierarchical feedback for the linear modeling and participating individual community communities. scores were analyzed in the context of the overall study

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Author(s), Article Domain Risk Protective Type of Intervention Other Sample Study Design Outcomes Key Finding(s) Study Limitations title (Individual, Family, Factor(s) Factor(s) Independent Characteristics (Instrument and Measure(s) School, Peer, and Variable(s) (Target Time Frame) Community/ Population) Environment) Paulozzi, Leonard Community/ None None State prescription drug (1) Median age of 51 jurisdictions U.S. mortality data by The effects of For all states (with (1) Studies at the J., Kilbourne, Environment discussed; discussed monitoring programs the population; (50 states and state and by year for PDMPs over and without population level are Edwin M., Desai, reviewers (PDMPs) (2) proportions of DC) 1999–2005 time on: (1) PDMPs) mean unable to identify Hema A. (2011), infer over racial groups in were obtained from drug overdose drug overdose associations at the Prescription drug and/or population; (3) multiple cause of mortality; (2) and opioid-related individual level; (2) monitoring inappropriate median death mortality files opioid overdose mortality adjustment for other programs and prescribing household produced by the overdose- rates rose factors that were death rates from and doctor- income; (4) National Center for related substantially and more difficult to drug overdose. shopping percentages of Health Statistics; mortality; (3) consistently 1999– quantify. For Pain Medicine, 12, high school and additional data morphine 2005. PDMPs example, patterns of 747–754. college graduates included: (1) Wide- milligram were not treatment, by state and year; ranging Online Data equivalents significantly preventive measures (5) proportions of for Epidemiologic (MME) associated with such as changes in state populations Research lower rates of drug state regulations, or living in counties; (WONDER) system, overdose, opioid the availability of (6) state- and (2) Automation of overdose street drugs, was not year-specific Reports and mortality, or lower possible. Therefore, retail distributions Consolidated Orders rates of this study cannot of prescription System (ARCOS) of consumption of rule out residual opioids; (7) state- the U.S. Drug opioid drugs. confounding that and year-specific Enforcement PDMP states may have obscured quantities of Administration. consumed a protective effect of seven of the most significantly PDMPs; (3) lack of commonly greater amounts pre/post design; (4) prescribed opioid of hydrocodone study could not drugs; (8) and lower evaluate the morphine amounts of all potential benefits milligram other Schedule II other than equivalents; (9) opioids (i.e., prevention of presence or oxycodone, overdose fatalities absence of an fentanyl, etc.). that might have operational Increases in resulted from PDMP and overdose mortality PDMPs. “proactive” rates and use of PDMPs prescription opioid drugs between1999- 2005 were Developed under the Substance Abuse and Mental Health Services Administration’s Center for the Application of Prevention Technologies contract. Reference #HHSS277200800004C. For training and/or technical assistance use only.

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Author(s), Article Domain Risk Protective Type of Intervention Other Sample Study Design Outcomes Key Finding(s) Study Limitations title (Individual, Family, Factor(s) Factor(s) Independent Characteristics (Instrument and Measure(s) School, Peer, and Variable(s) (Target Time Frame) Community/ Population) Environment) significantly less in PDMP states that required use of special prescription forms.

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Author(s), Article Domain Risk Protective Type of Intervention Other Sample Study Design Outcomes Key Finding(s) Study Limitations title (Individual, Family, Factor(s) Factor(s) Independent Characteristics (Instrument and Measure(s) School, Peer, and Variable(s) (Target Time Frame) Community/ Population) Environment) Schinke, Steven P., Individual, Family None (1)Positive Computer-delivered None discussed Adolescent girls Randomized clinical (1) Substance At 2-year follow- (1) Follow-up did not Fang, Lin, Cole, discussed outcomes on program for (ages 11-13) and trial conducted in use; (2) risk up, girls who include highest risk Kristin C. (2009). communicatio mother/daughter dyads their mothers 2006, 2007, 2008, and and protective participated in years for substance Computer- n with their to prevent substance from greater New 2009; baseline and factors computer- abuse; (2) delivering delivered, parent- mothers; (2) use among adolescent York City area two annual follow-up delivered program content by involvement closeness to girls [mother-daughter surveys; intervention prevention computer restricts Intervention to their mothers; dyads (n=916) participants received program reported the reach of the prevent (3) enrolled] annual booster higher protective material to substance use knowledge of sessions after each factors as well as households among adolescent family rules follow-up less past 30-day equipped with girls. Prevention about measurement; nine use of alcohol, personal computers; Medicine, 49(5), substance 45-minute sessions; marijuana, illicit (3) sample was from 429–435. use; (4) sessions were prescription drugs, a large urbanized awareness of delivered through and inhalants. region of the parental voice-over narration; Mothers of Northeastern U.S. monitoring of skills demonstrations participating girls limiting their by animated showed more generalization; (4) extracurricular characters; interactive positive 2-year mothers in sample activities; (5) exercises for mothers outcomes than were well-educated ability to cope and daughters to mothers of girls and may not typify with stress; (7) complete jointly. who did not parents in need of recognition participate on programs to prevent that variables linked adolescent adolescent with reduced risks substance use substance use of substance use is not among their normative daughters, and behavior; (8) mothers reported drug refusal lower rates of self-efficacy weekly alcohol consumption.

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Author(s), Article Domain Risk Protective Type of Intervention Other Sample Study Design Outcomes Key Finding(s) Study Limitations title (Individual, Family, Factor(s) Factor(s) Independent Characteristics (Instrument and Measure(s) School, Peer, and Variable(s) (Target Time Frame) Community/ Population) Environment) Spoth, Richard, Family, School For Studies 1 Family and Brief universal (not None discussed. Middle school Three randomized Prescription These brief Difficult to generalize Trudeau, Linda, and 3, risk school targeted toward students from controlled trials with drug misuse universal to non-rural Shin, Chungyeol, factors were environments, prescription drug rural adolescents are assessed interventions had populations in other Ralston, Ekaterina, initiated use youth prevention) communities in presented. Study 1 using potential impact of parts of country Redmond, Cleve, of gateway competencies interventions. Study 1 Iowa and (1993-2008) data questions reducing Greenberg, Mark, drugs looked at family-based Pennsylvania in collected by written about lifetime prescription drug Feinberg, Mark. (alcohol, interventions and three studies. questionnaires during use of misuse among (April 2013) cigarettes or assigned participating Study 1: 446 home visits until barbiturates, adolescents and Longitudinal effects marijuana) at schools to either (a) families of sixth twelfth grade and tranquilizers, young adults in of universal baseline; for Preparing for the Drug graders from telephone interviews amphetamines comparison to preventive Study 2, Free Years (PDFY) communities with after twelfth grade. , narcotics. control sample in intervention participants which emphasizes fewer than 8500 Study 2 (1998-2011) Prescription all three studies. on prescription reported adolescent refusal skills residents and data collected via 45- drug misuse Significant drug misuse: Three higher levels or (b) the Iowa more than 15% minute machine- overall was differences randomized of baseline Strengthening Families school free or scored questionnaires identified by an between groups controlled trials with use so “high Program (ISFP) which reduced lunch. administered during index if any of were found for late adolescents risk” was strengthens family Study 2: seventh school class periods, the above four both high-risk and and young adults. participants protective factors or (c) graders (n=226 grade 7-12, and drug low-risk American Journal reported a control group. Study families) from 24 follow-up via categories had populations for of Public Health, having 2 assigned participating schools in telephone surveys. been used studies one and 103(4), 665-672. initiated 2 out schools to either (a) a districts with Study 3 (2002-2009), without a three, though for of 3 of these multi-component enrollments of machine-scored doctor's study 2 the high- gateway family- and school- fewer than 1200 questionnaires during orders. risk sample drugs based intervention, students of whom school class periods. Prescription showed stronger which combined the 20% or more opioid misuse effects. ISFP with Life Skills were free or was analyzed Training (LST) in reduced lunch. separately. school; (b) a school- Study 3: Two only LST intervention consecutive group or (c) a control cohorts of sixth group. Study 3 graders and assigned participating families (n=1064 schools to either (a) families) from 28 PROmoting School- school districts community-university ranging in size Partnerships to from 1300 to Enhance Resilience 5200 students (PROSPER) model with at least 15% Developed under the Substance Abuse and Mental Health Services Administration’s Center for the Application of Prevention Technologies contract. Reference #HHSS277200800004C. For training and/or technical assistance use only.

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Author(s), Article Domain Risk Protective Type of Intervention Other Sample Study Design Outcomes Key Finding(s) Study Limitations title (Individual, Family, Factor(s) Factor(s) Independent Characteristics (Instrument and Measure(s) School, Peer, and Variable(s) (Target Time Frame) Community/ Population) Environment) which links community free and reduced teams, public schools, lunch. and Cooperative Education System of land-grant universities to implement the ISFP curriculum or (b) a control group.

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Author(s), Article Domain Risk Protective Type of Intervention Other Sample Study Design Outcomes Key Finding(s) Study Limitations title (Individual, Family, Factor(s) Factor(s) Independent Characteristics (Instrument and Measure(s) School, Peer, and Variable(s) (Target Time Frame) Community/ Population) Environment) Spoth, Richard, Individual, Family, None Family and Study 1: Family- (1) Substance Randomized Two randomized Self-reports of Universal (1) Generalizability Trudeau, Linda, School discussed school focused use measures: controlled trials of controlled prevention lifetime and interventions have to other populations Shin, Chungyeol, preventive interventions: Schools (a) tobacco universal trials; Study 1: 60- to past-year potential for public unknown; (2) small Redmond, Cleve. interventions; assigned to the Iowa (cigarettes), (b) preventive 80- minute home prescription health impact by numbers of (2008). Long-term combination of Strengthening Families alcohol (c ) interventions interviews with drug misuse reducing some participants reported effects of universal the family- Program (ISFP), marijuana; (2) implemented in adolescent and types of prescription drug preventive focused and Preparing for the Drug family rural Iowa parents, follow-up prescription drug misuse, so use interventions school-based Free Years (PDFY), or demographics: communities with (twelfth grader), misuse among rates are sensitive to on prescription universal a control condition. (a) average mostly White completed computer- adolescents and small changes in drug misuse. interventions ISFP: 7x sessions number of middle-income assisted telephone young adults: numbers of users Addiction, 103, (stronger) focused on family risk children, (b) dual- middle school interviews Study 1: ISFP 1160–1168. and protective factors, parent family, (c) students. Study twelfth graders’ PDFY: 5x 2-hour average family 1: Study began in past year narcotic sessions, focused on income, (d) race; 1993, with 667 misuse was risk and protective (3) school/ sixth graders; significantly less factors for substance community follow-ups with than controls, as use; Study 2: Multi- characteristics: twelfth graders were ISFP 21- component family- (a) enrollment, (b) and 21 year-olds, year-olds’ life-time focused and school- number of included 457 and narcotic and based Intervention: classrooms, (c) 483 participants barbiturate misuse schools were assigned student Study 2: Study rates. Study 2: to the school-based achievement began in 1998 LST plus SFP 10- Life Skills Training ranks, (d) with seventh 14 showed (LST) plus a revised attendance, (e) graders (total significant effects ISFP (SFP 10–14), or a school lunch sample across on lifetime control condition. LST: program eligibility waves 2127); prescription drug 15 sessions taught by rates, (f) follow-ups with misuse at the trained teachers during population eleventh- and eleventh grade 40–45-minute regular twelfth graders follow-up, while classroom periods and included 1443 effects at the 5x boosters 1 year and 1212 twelfth grade later, focused on self- participants. follow-up were improvement, decision- marginally making, coping with significant. anxiety, cognitive and social skills training components.

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Author(s), Article Domain Risk Protective Type of Intervention Other Sample Study Design Outcomes Key Finding(s) Study Limitations title (Individual, Family, Factor(s) Factor(s) Independent Characteristics (Instrument and Measure(s) School, Peer, and Variable(s) (Target Time Frame) Community/ Population) Environment) Twombly, Eric C., Community/ None None Prescription drug Two focus Focus group with A three-fold Students reported Not generalizable Holtz, Kristen D., Environment discussed. discussed misuse prevention groups with eight seventh and eighth categorization that messages Agnew, Christine B. message strategies seventh graders grade students based (highly with positive (2011). Resonant and eight eighth on twenty drug resonant, alternatives and messages to graders in Atlanta prevention messages moderately refusal skills had prevent prescription metropolitan area within nine categories resonant, or little resonance, drug misuse by in March 2009; not resonant) but scare tactic teens. Journal of no racial, gender which define messages Alcohol and Drug or other the extent to resonated Education, 55(1), demographic which a strongly. 38-52. information about student reports the participants a message or their school is may influence provided nor do him or her and authors indicate peers to refrain how this sample from misusing was recruited prescription drugs

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REFERENCES

Baehren, D.F., Marco, C.A., Droz, D.E., Sinha, S., Callan, M., & Akpunonu, P. (2009). A Statewide Prescription Monitoring Program Affects Emergency Department Prescribing Behaviors. Annals of Emergency Medicine, 51(1), 19-23.

Center for Substance Abuse Prevention. Identifying and Selecting Evidence-Based Interventions Revised Guidance Document for the Strategic Prevention Framework State Incentive Grant Program. HHS Pub. No. (SMA)09-4205. Rockville, MD: Center for Substance Abuse Prevention, Substance Abuse and Mental Health Services Administration, 2009.

Clark, H.K., Ringwalt, C.L., Hanley, S., Shamblen, S.R., Flewelling, R.L., & Hano, M.C. (2010). Project SUCCESS' effects on the substance use of alternative high school students. Addictive Behaviors, 35, 209–217.

Cochella, S. & Bateman, K. (2011). Provider Detailing: An Intervention to Decrease Prescription Opioid Deaths in Utah. Pain Medicine, 12, S73–S76.

Fang, L., Schinke, S.P., & Cole, K.C.A. (2010). Preventing Substance Use Among Early Asian–American Adolescent Girls: Initial Evaluation of a Web-based, Mother–Daughter Program. Journal of Adolescent Health, 47, 529–532.

Gruenewald, P.J., Johnson, K., Shamblen, S.R., Ogilvie, K.A., & Collins, D. (2009). Reducing Adolescent Use of Harmful Legal Products: Intermediate Effects of a Community Prevention Intervention. Substance Use & Misuse, 44(14), 2080–2098.

Johnson, E.M., Porucznik, C.A., Anderson, J.W., & Rolfs, R.T. (2011). State-Level Strategies for Reducing Prescription Drug Overdose Deaths: Utah’s Prescription Safety Program. Pain Medicine, 12, S66–S72.

Johnson, K.W., Shamblen, S.R., Ogilvi, K.A., Collins, D., & Saylor, B. (2009). Preventing Youths’ Use of Inhalants and Other Harmful Legal Products in Frontier Alaskan Communities: A Randomized Trial. Prevention Science, 10, 298–312.

Johnson, K., Holder, H., Ogilvie, K., Collins, D., Courser, M., Miller, B., Moore, R., & Saltz, B. (2007). A Community Prevention Intervention to Reduce Youth from Inhaling and Ingesting Harmful Legal Products. Journal of Drug Education, 37(3), 227-247.

Looby, A., De Young, K.P., & Earleywine, M. (2013, in press). Challenging expectancies to prevent nonmedical prescription stimulant use: A randomized, controlled trial. Drug and Alcohol Dependence, 132, 362-268.

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Ogilvie, K.A., Moore, R.S., Ogilvie, D.C., Johnson, K.W., Collins, D.A., & Shamblen, S.R. (2008). Changing Community Readiness to Prevent the Abuse of Inhalants and Other Harmful Legal Products in Alaska. Journal of Community Health, 33(4), 248–258.

Paulozzi, L.J., Kilbourne, E.M., & Desai, H.A. (2011). Prescription Drug Monitoring Programs and Death Rates from Drug Overdose. Pain Medicine, 12, 747–754.

Schinke, S.P., Fang, L., & Cole, K.C. (2009). Computer-Delivered, Parent-Involvement Intervention to Prevent Substance Use among Adolescent Girls. Preventive Medicine, 49(5), 429–435.

Spoth, R., Trudeau, L., Shin, C., Ralston, E., Redmond, C., Greenberg, M., & Feinberg, M. (2013) Longitudinal Effects of Universal Preventive Intervention on Prescription Drug Misuse: Three Randomized Controlled Trials With Late Adolescents and Young Adults. American Journal of Public Health, 103(4), 665-672.

Spoth, R., Trudeau, L., Shin, C., & Redmond, C. (2008). Long-term effects of universal preventive interventions on prescription drug misuse. Addiction, 103, 1160–1168.

Twombly, E.C., Holtz, K.D., Agnew, C.B. (2011). Resonant Messages to Prevent Prescription Drug Misuse by Teens. Journal of Alcohol & Drug Education, 55(1), 38-52.

Developed under the Substance Abuse and Mental Health Services Administration’s Center for the Application of Prevention Technologies contract. Reference #HHSS277200800004C. For training and/or technical assistance use only.

Page 32

Opioid Overdose TOOLKIT:

FactsFa for Community Members FiveFi Essential Steps for First Reponders Information for Prescriberses SafetySa Advice for Patients & Family Members Recovering fromom Opioid Overdose ACKNOWLEDG&MENTS

Acknowledgments This publication was prepared for the Substance Abuse and Mental Health Ser- vices Administration (SAMHSA) by the Association of State and Territorial Health Officials, in cooperation with Public Health Research Solutions, under contract number 10-233-00100 with SAMHSA, U.S. Department of Health and Human Services (HHS). LCDR Brandon Johnson, M.B.A., served as the Government Project Officer. Disclaimer The views, opinions, and content of this publication are those of the authors and do not necessarily reflect the views, opinions, or policies of SAMHSA or HHS. Public Domain Notice All materials appearing in this volume except those taken directly from copyrighted sources are in the public domain and may be reproduced or copied without permission from SAMHSA or the authors. Citation of the source is appreciated. However, this publication may not be reproduced or distributed for a fee without the specific, written authorization of the Office of Communications, SAMHSA, HHS. Electronic Access and Copies of Publication This publication may be ordered from SAMHSA’s Publications Ordering Web page at http://www.store.samhsa.gov/. Or, please call SAMHSA at 1-877- SAMHSA-7 (1-877-726-4727) (English and Español). Recommended Citation Substance Abuse and Mental Health Services Administration. SAMHSA Opioid Overdose Prevention Toolkit. HHS Publication No. (SMA) 1-4742. Rockville, MD: Substance Abuse and Mental Health Services Administration, 201. Originating Office Division of Pharmacologic Therapies, Center for Substance Abuse Treatment, Substance Abuse and Mental Health Services Administration, 1 Choke Cherry Road, Rockville, MD 20857. !"#$!

2 TABLETA OF CONTENTS

ACKNOWLEDGEMENTS...... 2

FACTS FOR COMMUNITY MEMBERS...... 4

FIVE ESSENTIAL STEPS FOR FIRST RESPONDERS ...... 8

INFORMATION FOR PRESCRIBERS ...... 11

SAFETY ADVICE FOR PATIENTS & FAMILY MEMBERS...... 18

RECOVERING FROM OPIOID OVERDOSE ...... 20

REFERENCES ...... 22

3 FACTS FOR COMMUNITY MEMBERS

SCOPE OF THE PROBLEM WHO IS AT RISK? Anyone who uses opi- overdose continues to be a major public health oids for long-term management of chronic prob cancer or non-cancer pain is at risk for opioid 1 overdose, as are persons who use heroin [5]. Others at risk include persons who are: Receiving rotating opioid medication regimens (and thus are at risk for incompletecross-tolerance). Discharged from emergency medical care following opioid intoxication or WHAT ARE OPIOIDS? Opioids include illegal drugs such as hero- poisoning. in, as well as prescription medications used to treat pain such as morphine, codeine, methadone, oxycodone (OxyContin®, Perco- &'& * + $ + dan&, Percocet&), hydrocodone (Vicodin&, Lortab&, Norco&), '9 9 + '; fentanyl (Duragesic&, Fentora&), hydromorphone (Dilaudid&, <& +9 Exalgo&), and buprenorphine (Subutex&, Suboxone&). &= + ; ;9+ Opioids work by binding to specific receptors in the brain, spinal cord and gastrointestinal tract. In doing so, they minimize the >9'9=?+ body’s perception of pain. However, stimulating the opioid recep- cation or abstinent for a period of time tors or “reward centers” in the brain also can trigger other systems (and presumably with reduced opioid of the body, such as those responsible for regulating mood, tolerance and high risk of relapse to breathing and blood pressure. opioid use). HOW DOES OVERDOSE OCCUR? A variety of effects can occur af- Recently released from incarceration ter a person takes opioids, ranging from pleasure to nausea, vomit- and a past user or abuser of opioids ing, severe allergic reactions (anaphylaxis) and overdose, in which (and presumably with reduced opioid breathing and heartbeat slow or even stop. tolerance and high risk of relapse to opioid use). Opioid overdose can occur when a patient deliberately misuses a prescription opioid or an illicit drug such as heroin. It also can   occur when a patient takes an opioid as directed, but the prescriber miscalculated the opioid dose or an error was made by the dispensing pharmacist or the patient misunderstood the directions for use. Also at risk is the person who takes opioid medications pre-     scribed for someone else, as is the individual who combines opioids — prescribed or illicit — with alcohol, certain other medications, and even some over-the-counter products that depress breathing, heart rate, and other functions of the central nervous system [4].

FACTS FOR COMMUNITY MEMBERS

STRATEGIES TO PREVENT OVERDOSE DEATHS

          !      "         # Federally funded Continuing Medical Education courses are available to providers  at no charge at http://www.OpioidPrescribing.com (six courses funded by the Substance Abuse and Mental Health Services Administration) and on Medscape (two    courses funded by the National Institute on Drug Abuse).    Helpful information for laypersons on how to prevent and manage overdose is     available from Project Lazarus at http://www.projectlazarus.org/ or from the Massachusetts Health Promotion Clearinghouse at http://www.maclearinghouse.org.      STRATEGY 2: Ensure access to treatment for individuals who are misusing or addicted to opioids or who have other substance use disorders. Effective treatment of substance   use disorders can reduce the risk of overdose and help overdose survivors attain a healthier life. Medication-assisted treatment, as well as counseling and other supportive    services, can be obtained at SAMHSA-certified and DEA-registered opioid treatment programs (OTPs), as well as from physicians who are trained to provide care in office- based settings with medications such as buprenorphine and naltrexone.

Information on treatment services available in or near your community can be     obtained from your state health department, state alcohol and drug agency, or from the    federal Substance Abuse and Mental Health Services Administration (see page 7).    STRATEGY 3: Ensure ready access to naloxone. Opioid overdose-related deaths can be prevented when naloxone is administered in a timely manner. As a narcotic antagonist,   naloxone displaces opiates from receptor sites in the brain and reverses respiratory   depression that usually is the cause of overdose deaths [5]. During the period of time when an overdose can become fatal, respiratory depression can be reversed by giving    the individual naloxone [4].     On the other hand, naloxone is not effective in treating overdoses of benzodiazepines (such as Valium&, Xanax&, or Klonopin&), barbiturates (Seconal& or    Fiorinal&), clonidine, Elavil&, GHB, or ketamine. It also is not effective in overdoses with  stimulants, such as cocaine and amphetamines (including methamphetamine and Ecstasy). However, if opioids are taken in combination with other sedatives or    stimulants, naloxone may be helpful. Naloxone injection has been approved by FDA and used for more than 40 years by emergency medical services (EMS) personnel to reverse opioid overdose and resuscitate persons who otherwise might have died in the absence of treatment [6].

FACTS FOR COMMUNITY MEMBERS

Naloxone has no psychoactive effects and does not present any poential for abuse [1, 4]. Injectable naloxone is relatively inexpensive. It typically is supplied as a kit with two syringes, at a cost of about $6 per dose and $15 per kit [7]. These kits require training on how to administer naloxone using a syringe. The FDA has also approved a naloxone automated injector, called Evzio® which does not require special training to use because it has verbal instructions which are activated when the cap is removed from the device. This autoinjector can deliver a dose of naloxone through clothing when placed on the outer thigh muscle. The per dose cost of naloxone via the autoinjector is not yet determined.

For these reasons, it is important to determine whether local EMS personnel or  other first responders have been trained to care for overdose, and whether they are    allowed to stock naloxone in their drug kits. In some jurisdictions, the law protects responders from civil liability and criminal prosecution for administering naloxone.   Socalled “Good Samaritan” laws are in effect in 10 states and the District of Columbia, and are being considered by legislatures in at least a half-dozen other states [8]. Such laws provide protection against prosecution for both the overdose victim and those who respond to overdose. To find states that have adopted relevant laws, visit the CDC’s website at: http://www.cdc.gov/HomeandRecreational Safety/Poisoning/laws/immunity.html.  STRATEGY 4: Encourage the public to call 911. An individual who is experiencing     opioid overdose needs immediate medical attention. An essential first step is to get help from someone with medical expertise as quickly as possible [9, 10]. Therefore,   members of the public should be encouraged to call 911. All they have to say is, “Someone is not breathing” and give a clear address and location.     STRATEGY 5: Encourage prescribers to use state Prescription Drug Monitoring  Programs (PDMPs). State Prescription Drug Monitoring Programs (PDMPs) have emerged as a key strategy for addressing the mis-use and abuse of prescription   opioids and thus preventing opioid overdoses and deaths. Specifically, prescribers can check their state’s PDMP database to determine whether a patient is filling the prescriptions provided and/or obtaining prescriptions for the same or similar drug from multiple prescribers.

While a majority of states now have operational PDMPs, the programs differ from state to state in terms of the exact information collected, how soon that information is available to prescribers, and who may access the data. Therefore, information about the program in a

FACTS FOR COMMUNITY MEMBERS

RESOURCES FOR COMMUNITIES Resources that may be useful to local communities and organizations are found at the following websites: Substance Abuse and Mental ealth Services Administration (SAMHSA) National Treatment Referral Helpline      1-800-662-HELP (4357) or 1-800-487-4889 (TDD — for hearing impaired)   

National Substance Abuse Treatment Facility Locator:     http://www.findtreatment.samhsa.gov/TreatmentLocator/ to &=;=;=;Y    G

Buprenorphine Physician & Treatment Program Locator: http://www.buprenorphine.samhsa.gov/bwns_locator

State Substance Abuse Agencies:

Center for Behavioral Health Statistics and Quality (CBHSQ): http://www.samhsa.gov/data/

SAMHSA Publications: http://www.store.samhsa.gov 1-877-SAMHSA (1-877-726-4727)

Centers for Disease Control and Prevention (CDC) http://www.cdc.gov/Features/VitalSigns/PainkillerOverdoses http://www.cdc.gov/HomeandRecreationSafety/Poisoning

White ouse Office of National Drug Control Policy (ONDCP) State and Local Information: http://www.whitehouse.gov/ondcp/state-map

Association of State and Territorial ealth Officials (ASTHO) Prescription Drug Overdose: State Health Agencies Respond (2008): http://www.astho.org/PreventingPrescriptionDrugOverdose

National Association of State Alcohol and Drug Abuse Directors (NASADAD) '; ^' ; ` # +9 ^^ 9& {|= &`}}'}<}}!}!~}^^ ^'{|=#+

American Association for the Treatment of Opioid Dependence (AATOD) Prevalence of Prescription Opioid Abuse: http://www.aatod.org/

FIVE ESSENTIAL STEPS FOR FIRST RESPONDERS

verdose is common among STEP 1: CALL FOR HELP (DIAL 911) persons who use illicit opioids O such as heroin and among AN OPIOID OVERDOSE NEEDS IMMEDIATE MEDICAL those who misuse medica- ATTENTION. An essential step is to get someone with medical tions prescribed for pain, such as ox- expertise to see the patient as soon as possible, so if no EMS or ycodone, hydrocodone, and morphine. other trained personnel are on the scene, dial 911 immediately. All The incidence of opioid overdose is ris- you have to say is: “Someone is not breathing.” Be sure to give a ing nationwide. For example, between clear address and/or description of your location. 2001 and 2010, the number of poison- ing deaths in the United States nearly STEP 2: CHECK FOR SIGNS OF doubled, largely because of overdoses involving prescription opioid analgesics OPIOID OVERDOSE [1]. This increase coincided with a Signs of OVERDOSE, which often results in death if not nearly fourfold increase in the use of treated, include []: prescribed opioids for the treatment of pain []. Extreme sleepinessinability to awaken verbally or upon ster- To address the problem, emergency nal rub medical personnel, health care profes- Breathing problemscan range from slow to shallow breath- sionals, and patients increasingly are ing in a patient that cannot be awakened being trained in the use of the opioid antagonist naloxone hydrochloride (na- Fingernails or lips turning blue/purple loxone), which is the treatment of Extremely small “pinpoint” pupils choice to reverse the potentially fatal respiratory depression caused by opi- Slow heartbeat and/or low blood pressure oid overdose. (Note that naloxone has Signs of OVERMEDICATION, which may progress to no effect on non-opioid overdoses, overdose, include []: such as those involving cocaine, ben- zodiazepines, or alcohol ].) Unusual sleepiness, drowsiness, or difficulty staying awake Based on current scientific evi- despite loud verbal stimulus or vigorous sternal rub dence and extensive experience, the Mental confusion, slurred speech, intoxicated behavior steps outlined below are recom- mended to reduce the number of Slow or shallow breathing deaths resulting from opioid Extremely small “pinpoint” pupils; although normal size pupils overdoses do not exclude opioid overdose Slow heartbeat, low blood pressure Difficulty waking the person from sleep. Because opioids depress respiratory function and breathing, one telltale sign of a person in a critical medical state is the “death rat- tle.” If a person emits a “death rattle” — an exhaled breath with a very distinct, labored sound coming from the throat — emergency resuscitation will be necessary immediately, as it almost always is a sign that the individual is near death [].

 FIVE ESSENTIAL STEPS FOR FIRST RESPONDERS STEP 3: SUPPORT THE PERSON’S More than one dose of naloxone may be needed to revive someone who is overdos- BREATHING ing. Patients who have taken longer-acting Ideally, individuals who are experiencing opioid overdose opioids may require further intravenous bolus should be ventilated with 100% oxygen before naloxone is ad- doses or an infusion of naloxone [ ]. Comfort the person being treated, as with- ministered so as to reduce the risk of acute lung injury [,]. In drawal triggered by naloxone can feel un- situations where 100% oxygen is not available, rescue breathing pleasant. As a result, some persons become can be very effective in supporting respiration []. Rescue breath- agitated or combative when this happens and ing for adults involves the following steps: need help to remain calm. Be sure the person's airway is clear (check that nothing SAFETY OF NALOXONE. The safety profile inside the person’s mouth or throat is blocking the airway). of naloxone is remarkably high, especially Place one hand on the person's chin, tilt the head back and when used in low doses and titrated to effect pinch the nose closed. When given to individuals who are not opioid-intoxicated or opioid- Place your mouth over the person's mouth to make aseal dependent, naloxone produces no clinical and give 2 slow breaths. effects, even at high doses. Moreover, while The person's chest should rise (but not the stomach). rapid opioid withdrawal in tolerant patients Follow up with one breath every 5 seconds. may be unpleasant, it is not life-threatening. Naloxone can safely be used to manage STEP 4: ADMINISTER NALOXONE opioid overdose in pregnant women. The lowest dose to maintain spontaneous respira- Naloxone should be administered to any person who shows tory drive should be used to avoid triggering signs of opioid overdose, or when overdose is suspected [4]. acute opioid withdrawal, which may cause Naloxone injection is approved by the FDA and has been used for fetal distress [4]. decades by emergency medical services (EMS) personnel to On April 3, 2014 the FDA approved a new reverse opioid overdose and resuscitate individuals who have naloxone delivery device call Evzio®1(nalox- overdosed on opioids. one hydrochloride injection.) The device rap- Naloxone can be given by intramuscular, subcutaneous, or idly delivers a single dose of the drug nalox- intravenous injection every 2 to 3 minutes [ - ]. The most one via a hand-held auto-injector that can be +&$=$9; carried in a pocket or stored in a medicine <&&999'="ƒ & cabinet. The currently available naloxone kits &&9++$&9 that include a syringe and naloxone ampules 9=$ or vials require the user to be trained on how Opioid-naive patients may be given starting doses of up to 2 to fill the syringe with naloxone and adminis- mg without concern for triggering withdrawal symptoms ter it to the victim. No special training is re- ƒ quired to use Evzio&. The intramuscular route of administration may be more suitable for patients with a history of opioid dependence because it Evzio& is injected into the muscle provides a slower onset of action and a prolonged duration of (intramuscular) or under the skin effect, which may minimize rapid onset of withdrawal symptoms (subcutaneous).Once turned on, the device provides verbal instruction to the user DURATION OF EFFECT. The duration of effect of naloxone is 30 describing how to deliver the medication, to 90 minutes depending on dose and route of9; and similar to automated defibrillators. patients should be observed after this time frame for the return of overdose symptoms The goal of naloxone therapy ` &`}}<<<+'$}<†$}<9}9} should be to restore adequate spontaneous breathing, but not 9"‡~ˆ&9 necessarily complete arousal  FIVE ESSENTIAL STEPS FOR FIRST RESPONDERS

STEP 5: MONITOR THE PERSON’S SUMMARY: RESPONSE Do’s and Don’ts in Responding to All patients should be monitored for recurrence of signs and Opioid Overdose symptoms of opioid toxicity for at least 4 hours from the last dose DO support the person’s breathing by of naloxone or discontinuation of the naloxone infusion. Patients administering oxygen or performing who have overdosed on long-acting opioids should have more rescue breathing. prolonged monitoring Most patients respond by returning to spontaneous DO administer naloxone. breathing, with minimal withdrawal symptoms []. The response DO put the person in the “recovery po- generally occurs within 3 to 5 minutes of naloxone sition” on the side, if he or she is administration. (Rescue breathing should continue while waiting breathing independently. for the naloxone to take effect. ) Naloxone will continue to work for 30 to 90 minutes, but after DO stay with the person and keephim/ that time, overdose symptoms may return [,]. Therefore, it her warm. is essential to get the person to an emergency department or DON'T slap or try to forcefully stimulate other source of medical care as quickly as possible, even if he the person — it will only cause further or she revives after the initial dose of naloxone and seems to injury. If you are unable to wake the feel better. person by shouting, rubbing your knuckles on the sternum (center of the SIGNS OF OPIOID WITHDRAWAL. The signs and symptoms chest or rib cage), or light pinching, he of opioid withdrawal in an individual who is physically dependent or she may be unconscious. on opioids may include, but are not limited to, the following: body aches, diarrhea, tachycardia, fever, runny nose, sneezing, DON'T put the person into a cold bath piloerection, sweating, yawning, nausea or vomiting, nervous- or shower. This increases the risk of ness, restlessness or irritability, shivering or trembling, falling, drowning or going into shock. abdominacramps, weakness, and increased blood pressure. In DON'T inject the person with any sub- the neonate, opioid withdrawal may also include convulsions, stance (salt water, milk, “speed,” hero- excessive crying, and hyperactive reflexes []. in, etc.). The only safe and appropriate NALOXONE NON-RESPONDERS. If a patient does not re- treatment is naloxone. spond to naloxone, an alternative explanation for the clinical symptoms should be considered. The most likely explanation is DON'T try to make the person vomit that the person is not overdosing on an opioid but rather some drugs that he or she may have swal- other substance or may even be experiencing a non-overdose lowed. Choking or inhaling vomit into medical emergency. A possible explanation to consider is that the lungs can cause a fatal injury. the individual has overdosed on buprenorphine, a long-acting NOTE: ?&$? opioid partial agonist. Because buprenorphine has a higher af- ;9&*&? finity for the opioid receptors than do other opioids, naloxone 9? may not be effective at reversing the effects of buprenorphine $ƒ

In all cases, support of ventilation, oxygenation, and blood pressure should be sufficient to prevent the complications of opioid overdose and should be given priority if the response to naloxone is not prompt.

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ADMINISTER NALOXONE. Naloxone competitively binds opi- SIGNS OF OPIOID WITHDRAWAL: oid receptors and is the antagonist of choice for the reversal of Withdrawal triggered by naloxone can feel acute opioid toxicity. It should be given to any patient who pre- unpleasant. As a result, some persons sents with signs of opioid overdose, or when overdose is sus- become agitated or combative when this pected [4]. Naloxone can be given by intramuscular, subcutane- happens and need help to remain calm. ous or intravenous injection every 2 to 3 minutes ;"ƒ The signs and symptoms of opioid with- The most rapid onset of action is achieved by intravenous drawal in an individual who is physically de- administration, which is recommended in emergency situations pendent on opioids may include (but are not [13]. The intramuscular route of administration may be more suit- limited to) the following: body aches, diar- able for patients with a history of opioid dependence because it rhea, tachycardia, fever, runny nose, sneez- provides a slower onset of action and a prolonged duration of ef- ing, piloerection, sweating, yawning, nausea fect, which may minimize rapid onset of withdrawal symptoms or vomiting, nervousness, restlessness or [4]. The product Evzio&is specifically designed for intramuscu- irritability, shivering or trembling, abdominal lar use but may also be administered subcutaneously. cramps, weakness, and increased blood The intramuscular or subcutaneous route of administration pressure ["]. Withdrawal syndromes maybe precipitated by as little as 0.05 to 0.2 mg may be more suitable for patients with a history of opioid intravenous naloxone in a patient taking 24 dependence because it provides a slower onset of action and a mg per day of methadone. prolonged duration of effect, which may minimize rapid onset of In neonates, opioid withdrawal also may withdrawal symptoms []. produce convulsions, excessive crying, and Pregnant patients. Naloxone can be used safely to manage opi- hyperactive reflexes ["]. Additionally, in oid overdose in pregnant women. The lowest dose to maintain neonates, opiate withdrawal may be life- spontaneous respiratory drive should be used to avoid triggering threatening if not recognized and properly acute opioid withdrawal, which may cause fetal distress []. treated. NALOXONE NON-RESPONDERS: If a pa- MONITOR THE PATIENT’S RESPONSE. Patients should be tient does not respond to naloxone, an al- monitored for re-emergence of signs and symptoms of opioid ternative explanation for the clinical symp- toxicity for at least 4 hours following the last dose of naloxone toms should be considered. The most likely (however, patients who have overdosed on long-acting opioids explanation is that the person is not over- require more prolonged monitoring) []. dosing on an opioid but rather some other Most patients respond to naloxone by returning to spon- substance or may even be experiencing a taneous breathing, with mild withdrawal symptoms []. non-overdose medical emergency. Another The response generally occurs within 3 to 5 minutes of possible explanation to consider is that the naloxonadministration. (Rescue breathing should continue individual has overdosed on buprenorphine, while waitin'for the naloxone to take effect.) a long-acting opioid partial agonist. Because buprenorphine has a higher affinity for the The duration of effect of naloxone is 30 to 90 minutes de- opioid receptors than do other opioids, na- pending on dose and route of administration. Patients should be loxone may not be effective at reversing the observed after that time for re-emergence of overdose effects of buprenorphine-induced opioid symptoms. The goal of naloxone therapy should be restoration overdose []. of adequate spontaneous breathing, but not necessarily In all cases, support of ventilation, oxy- complete arousal [;"-1]. genation, and blood pressure should be suf- ficient to prevent the complications of opioid &+?9=|$$ overdose and should be given the highest & &<&&$*'' priority if the patient’s response to naloxone '9=|+&9=| is not prompt. +&$++?ƒ. Therefore, it is essential to get the person to an emergency de- NOTE: All naloxone products have an expiration partment or other source of acute care as quickly as possible, date. It is important to check the expiration date and even if he or she revives after the initial dose of naloxone and obtain replacement naloxone as needed. seems to feel better.

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WHAT ARE OPIOIDS? IF YOU SUSPECT AN pioids include illicit drugs such as heroin and prescription 9&9&; OVERDOSE ;9&;?=Š?=>&;&; &;&=‹&;Œ&;&; An opioid overdose requires imme- O +=^'&;&;&=9&^ diate medical attention. An essential first step is to get help from some- ;Exalgo), and buprenorphine (Suboxone&). one with medical expertise as soon Opioids work by binding to specific receptors in the brain, as possible. spinal cord and gastrointestinal tract. In doing so, they minimize Call 911 immediately the body’s perception of pain. However, stimulating the opioid if you or someone

receptors or “reward centers” in the brain also can trigger other you know exhibits any of the symptoms systems of the body, such as those responsible for regulating listed below. All you have to say: “Some-

mood, breathing, and blood pressure. one is unresponsive and not breathing.”

A variety of effects can occur after a person takes opioids, Give a clear address and/or description of

ranging from pleasure to nausea, vomiting, severe allergic reac- your location. tions (anaphylaxis) to overdose, in which breathing and heart- Signs of OVERDOSE, which is beat slow or even stop. a life- threatening emergency, Opioid overdose can occur when a patient misunderstands include: the directions for use, accidentally takes an extra dose, or de- Face is extremely pale and/or clammy to liberately misuses a prescription opioid or an illicit drug such as the touch heroin. Body is limp Also at risk is the person who takes opioid medications pre- Fingernails or lips have a blue or purple scribed for someone else, as is the individual who combines opi- cast oids — prescribed or illicit — with alcohol, certain other medica- tions, and even some over-the-counter products that depress The patient is vomiting or making gur- breathing, heart rate, and other functions of the central nervous gling noises system [4]. He or she cannot be awakened from PREVENTING OVERDOSE sleep or is unable to speak Breathing is very slow or stopped If you are concerned about your own use of opioids, don’t wait! Heartbeat is very slow or stopped. Talk with the health care professional/s who prescribed the med- ications for you. If you are concerned about a family member or Signs of OVERMEDICATION, which friend, urge him or her to do so as well. may progress to overdose, include: Effective treatment of opioid use disorders can reduce the risk Unusual sleepiness or drowsiness of overdose and help a person who is misusing or addicted to Mental confusion, slurred opioid medications attain a healthier life. An evidence-based speech, intoxicated behavior practice for treating opioid addiction is the use of FDA-approved medications, along with counseling and other supportive Slow or shallow breathing services. These services are available at SAMHSA-certified and Pinpoint pupils DEA-registered opioid treatment programs (OTPs) [19-20]. In addition, physicians who are trained to provide treatment for Slow heartbeat, low blood pressure opioid addiction in office-based and other settings with Difficulty waking the person from sleep. medications such as buprenor-phine/naloxone and naltrexone may be available in your community [21].

18 SAFETY ADVICE FOR PATIENTS & FAMILY MEMBERSS

WHAT IS REPORT ANY SIDE STORE NALOXONE NALOXONE? EFFECTS IN A SAFE PLACE Naloxone is an antidote to Get emergency medical help if you have Naloxone is usually handled and opioid overdose. It is an any signs of an allergic reaction after tak- stored by a health care provider. opioid antagonist that is ing naloxone, such as hives, difficulty If you are using naloxone at home, used to reverse the effects breathing, or swelling of your face, lips, store it in a locked cabinet or other of opioids. Naloxone works tongue, or throat. space that is out of the reach of by blocking opiate receptor children or pets. sites. It is not effective in Call your doctor or 911 at once if you have a serious side effect such as: treating overdoses of ben- SUMMARY: HOW TO zodiazepines (such as Vali- Chest pain, or fast or irreg- um&, Xanax&, or ular heartbeats; AVOID OPIOID Klonopin&), barbiturates Dry cough, wheezing, or feeling OVERDOSE (Seconal& or Fiorinal&), short of breath; clonidine, Elavil&, GHB, or 1. Take medicine only if it has been Sweating, severe nausea, or vomiting; ketamine. It also is not prescribed to you by your doctor. effective in treating Severe headache, agitation, 2. Do not take more medicine or anxiety, confusion, or ringing in overdoses of stimulants take it more often than instructed. your ears; such as cocaine and am- 3. Call a doctor if your pain gets phetamines (including Seizures (convulsions); worse. methamphetamine and Ec- Feeling that you might pass out; or 4. Never mix pain medicines with stasy). However, if opioids Slow heart rate, weak pulse, faint- alcohol, sleeping pills, or any illicit are taken in combination ing, or slowed breathing. substance. with other sedatives or 5. Store your medicine in a safe stimulants, naloxone may If you are being treated for dependence place where children or pets can- be helpful. on opioid drugs (either an illicit drug like not reach it. heroin or a medication prescribed for IMPORTANT SAFETY 6. Learn the signs of overdose and pain), you may experience the following INFORMATION. Naloxone how to use naloxone to keep it may cause dizziness, symptoms of opioid withdrawal after taking from becoming fatal. drowsiness, or fainting. naloxone: 7. Teach your family and friends These effects may be worse Feeling nervous, restless, or irrita- how to respond to an overdose. if it is taken with alcohol or ble; 8. Dispose of unused medication certain medicines. Use na- properly. loxone with caution. Do not Body aches; drive or perform other pos- Dizziness or weakness; sibly unsafe tasks until you READ MORE AT http://www.drugs. Diarrhea, stomach pain, or mild know how you react to it. com/cdi/naloxone.html. If you experience a return nausea; of symptoms (such as Fever, chills, or goosebumps; or drowsiness or difficulty Sneezing or runny nose in the ab- breathing), get help imme- sence of a cold. diately. This is not a complete list of side ef- fects, and others may occur. Talk to your doctor about side effects and how to deal with them.

19 RECOVERINGRE FROM OPIOID OVERDOSE

In addition to receiving support from fami- RESOURCES FOR OVERDOSE ly and friends, overdose survivors can ac- SURVIVORS AND FAMILY MEM- cess a variety of community-based organi- zations and institutions, such as: BERS Health care and behavioral health urvivors of opioid overdose have experienced a life- providers changing and traumatic event. They have had to deal Peer-to-peer recovery support groups with the emotional consequences of overdosing, which S such as Narcotics Anonymous can involve embarrassment, guilt, anger, and gratitude, all accompanied by the discomfort of opioid withdrawal. Most Faith-based organizations need the support of family and friends to take the next steps Educational institutions toward recovery. While many factors can contribute to opioid overdose, it is al- Neighborhood groups most always an accident. Moreover, the underlying problem that Government agencies led to opioid use — most often pain or substance use disorder — still exists and continues to require attention [2]. Family and community support pro- Moreover, the individual who has experienced an overdose grams. is not the only one who has endured a traumatic event. Family members often feel judged or inadequate because they could not prevent the overdose. It is important for families to work to- gether to help the overdose survivor obtain the help that he or she needs. FINDING A NETWORK OF SUPPORT As with any disease, it is not a sign of weakness to admit that a person or a family cannot deal with the trauma of overdose with- out help. It takes real courage to reach out to others for support and to connect with members of the community to get help. Health care providers, including those who specialize in treating substance use disorders, can provide structured, therapeutic support and feedback. If the survivor’s underlying problem is pain, referral to a pain specialist may be in order. If it is addiction, the patient should be referred to an addiction specialist for assessment and treatment, either by a physician specializing in the treatment of opioid addic- tion, in a residential treatment program, or in a federally certified Opioid Treatment Program (OTP). In each case, counseling can help the individual manage his or her problems in a healthier way. Choosing the path to recovery can be a dynamic and challenging process, but there are ways to help.

20 RECOVERINGRE FROM OPIOID OVERDOSE

RESOURCES Information on opioid overdose and helpful advice for overdose survivors and their families can be found at the following websites: Substance Abuse and Mental ealth Services Administration (SAMHSA) National Treatment Referral Helpline 1-800-662-HELP (4357) or 1- 800-487-4889 (TDD — for hearing impaired) National Substance Abuse Treatment Facility Locator: http://www.findtreatment.samhsa.gov/TreatmentLocator to search by state, city, county, and zip code Buprenorphine Physician & Treatment Program Locator: http://www.buprenorphine.samhsa.gov/bwns_locator State Substance Abuse Agencies: http://www.findtreatment.samhsa.gov/TreatmentLocator/faces/abuse- Agencies.jspx

Centers for Disease Control and Prevention (CDC): http://www.cdc.gov/Features/VitalSigns/PainkillerOverdoses

National Institutes of Health (NIH), National Center for Biotechnical Information: http://www.ncbi.nlm.nih.gov

The Partnership at Drug-Free.org: http://www.drugfree.org/uncategorized/opioid-overdose-antidote

Project Lazarus: http://www.projectlazarus.org/

Harm Reduction Coalition: http://www.harmreduction.org/

Overdose Prevention Alliance: http://www.overdosepreventionalliance.org/

Toward the Heart: http://www.towardtheheart.com/naloxone

21 REFERENCESRE

1. Centers for Disease Control and Prevention (CDC), National Center for Health Statistics. CDC WONDER Online Database, 2012. 2. Beletsky LB, Rich JD, Walley AY. Prevention of fatal opioid overdose. JAMA. 2013; 308(180): 1863–1864. 3. Harvard Medical School. Painkillers fuel growth in drug addiction: Opioid overdoses now kill more people than cocaine or heroin. Harvard Ment Hlth Let. 2011; 27(7):4–5. 4. BMJ Evidence Centre. Treatment of opioid overdose with naloxone. British Medical Journal. Updated October 23, 2012. [Accessed March 24, 2013, at http://www.bmj.com] 5. Enteen L, Bauer J, McLean R, Wheeler E, Huriaux E, Kral AH, Bamberger JD. Overdose prevention and naloxone prescription for opioid users in San Francisco. J Urban Health. 2010 Dec; 87(6):931–941. 6. Seal KH, Thawley R, Gee L et al. Naloxone distribution and cardiopulmonary resuscitation training for injection drug users to prevent heroin overdose death: A pilot intervention study. J Urban Health. 2005; 82(2):303–311. 7. Coffin PO, Sullivan SD. Cost effectiveness of distributing naloxone to heroin users for lay overdose reversal. Ann Intl Med. 2013; 158:1–9. 8. Banta-Green C. Good Samaritan overdose response laws: Lessons learned from Washington State. Washington, DC: Office of National Drug Control Policy, Executive Office of the President, the White House, March 29, 2013. [Accessed at http://www.whitehouse.gov/blog/2013/03/29/good-samaritan- overdose-response-laws-lessonslearned-washington-state] 9. Strang J, Manning V, Mayet S et al. Overdose training and take-home nalox- one for opiate users: Prospective cohort study of impact on knowledge and attitudes and subsequent management of overdoses. Addiction. 2008; 103(10): 1648–1657. 10. Green TC, Heimer R, Grau LE. Distinguishing signs of opioid overdose and indication for naloxone: An evaluation of six overdose training and naloxone distribution programs in the United States. Addiction. 2008; 103(6): 979–98. 11. Hardman E, Limbird LE, eds. Goodman and Gilman’s the Pharmacologic Ba- sis of Therapeutics, 11th ed. New York, NY: McGraw-Hill, 2006, pp. 576– 578. 12. Centers for Disease Control and Prevention (CDC). Community-based opioid overdose prevention programs providing naloxone — United States, 2010. MMWR Morb Mortal Wkly Rep. 2012; 261(6):101–105.

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13. Rx List [Accessed March 24, 2013, at http://www.rxlist.com] 14. Drugs.com [Accessed March 24, 2013, at http://www.drugs.com] 15. Centers for Disease Control and Prevention (CDC). CDC grand rounds: Pre- scription drug overdoses — A U.S. epidemic. MMWR Morb Mortal Wkly Rep. 2012; 61(1):10–13. 16. Isaacson JH, Hopper JA, Alford DP, Parran T. Prescription drug use and abuse. Risk factors, red flags, and prevention strategies. Postgrad Med. 2005; 118:19. 17. Finch JW, Parran TV, Wilford BB, Wyatt SA. Clinical, legal and ethical con- siderations in prescribing drugs with abuse potential. In Ries RK, Alford DP, Saitz R, Miller S, eds. Principles of Addiction Medicine, Fifth Edition. Phila- delphia, PA: Lippincott, Williams & Wilkins, Ch. 109, in press 2013. 18. Michna E, Ross EL, Hynes WL, et al. Predicting aberrant drug behavior in patients treated for chronic pain: Importance of abuse history. J Pain Symp- tom Manage. 2004; 28:250. 19. National Treatment Referral Helpline 1-800-662-HELP (4357) or 1-800-487- 4889 (TDD for hearing impaired) 20. National Substance Abuse Treatment Facility Locator: http://www. findtreat- ment.samhsa.gov/TreatmentLocator to search by state, city, county, and zip code 21. Buprenorphine Physician & Treatment Program Locator: http://www.bupren- orphine.samhsa.gov/ bwns_locator 22. Bazazi AR, Zaller ND, Fu JJ, Rich JD. Preventing opiate overdose deaths: Examining objections to take-home naloxone. J Health Care Poor Under- served. 2010 Nov; 21(4):1108–1112.

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