The Florida Department of Health in Manatee County (DOH-Manatee) is in Bradenton, Florida, along the southwest coast on the Gulf of Mexico. In addition to Bradenton, DOH-Manatee serves 743.1 square miles, including the cities of Palmetto, Anna Maria Island, Bradenton Beach, Holmes Beach, and Lakewood Ranch. The demographics of the population served in Manatee County is as follows: current population is approximately 411,000; seasonal population is 73,000 and annual tourists is approximately 3,180,800. Race: White 86.2%; Black 9.1%; Asian 2.3%. Ethnicity: Hispanic or Latino 16.7%. Gender: male 48.3%; female 51.7%. Median age: 48.7 years. Median household income $56,000. In 2014, Manatee County became the epicenter for the opioid crisis with the highest rate of opioid overdose mortality in the state of Florida. This state of affairs at the time could be attributed to a multitude of reasons, including a lack of public awareness of the risk of prescription opioids and ongoing stigma associated with drug use and opioid use disorder. Manatee County also was and still is challenged by high rates of synthetic opioids, such as fentanyl, in its drug supply. Additionally, treatment options have persistently been limited, awareness of where to seek services is insufficient, and stigmas associated with existing treatment options remain.

With funding and technical assistance from National Association of County and City Health Officials (NACCHO) and in collaboration with the Centers for Disease Control and Prevention (CDC), DOH-Manatee was responsible for exploring, planning, and implementing innovative and collaborative approaches to support efforts to combat the opioid crisis within our community with a project, Local Opioid Overdose Prevention and Response (LOOPR) Program that was for the period January 2019 to July 31, 2019. The key goals were to increase the local health department’s (LHD) capacity to reduce fatal and non-fatal opioid overdoses, and to improve the community response to the opioid epidemic. The objectives were to develop and implement a Community Action Plan (CAP) to reduce fatal and non-fatal overdoses and community consequences of the opioid epidemic through prevention, harm reduction, and linkage to care; and monitor and evaluate CAP efforts. DOH-Manatee hosted the CAP meeting on February 14, 2019 with over 60 local, state, national and federal community partners. After discussion and a thorough Strengths, Opportunities, Weakness, and Threat (SWOT) analysis, three themes of prevention, harm reduction, and linkage to care were identified with four strategies to accomplish these themes. The first strategy under prevention included provision of educational classes to medical providers and medical students on opioid prescribing practices; the second and third strategies under the theme of harm reduction included a prescription opioid awareness campaign and provision of a statewide alternatives to opioid (ALTO) toolkit designed by Manatee Memorial Hospital; and, the fourth strategy under the theme of linkage to care included the evaluation of an Opioid-focused Recovery Peer Coach Pilot program.

Strategy one outcomes (medical provider and medical student education on opioid prescribing practices) included six classes delivered to a total of 85 health care providers and six classes delivered to a total of 81 medical students. Strategy two outcomes (a prescription opioid awareness campaign) included the provision of a digital and print media campaign via area transit buses, convenience stores and gas stations, Spectrum Cable TV, and local newspaper and movie theater agencies, with a combined reach of over 663,000 impressions/people. Strategy three outcomes (distribution of an ALTO Toolkit) included the actual development of the Toolkit with funding from a local hospital, then distributing the toolkit statewide to hospitals outside of Manatee County. Strategy four outcomes (the evaluation of an Opioid-focused Recovery Peer Coach Pilot program) included better understanding of linkages to care among people with Opioid Use Disorder (OUD), i.e. the receipt of referrals, receipt of resources, and follow up to treatment.

The objectives to develop and implement a CAP to reduce fatal and non-fatal overdoses and community consequences of the opioid epidemic through prevention, harm reduction, and linkage to care, and monitor and evaluate CAP efforts were all successfully met. Factors that led to the success of the CAP and to the successful implementation of the four strategies that came from the CAP began with subject matter experts presenting their research at the CAP. This laid the foundation for themes and strategies derived from the SWOT to be expert-driven, based in evidence, and also based in what the Manatee County community was experiencing at the time related to opioid use. Furthermore, over 60 new and existing DOH-Manatee partners attended the CAP which was instrumental in designing as well as implementing the four strategies. For example, the Narcan distribution data shared by partners who attended the CAP shaped the prescription opioid awareness campaign, distribution of ALTO Toolkits, and the educational classes because this data uncovered pockets of inequity in zip codes not previously on our radar. Specific demographics that were affected by the opioid overdose epidemic and may have otherwise fallen through the cracks were targeted by each of these three strategies instead.

The substantial public health impact of the CAP as well as the four strategies that were implemented in Manatee County as a result of the CAP is still felt today. To begin with, the CAP spurred the merging of two different Manatee County Task Forces focused on Pain Management and Addiction to merge into one Pain Management and Addictions Task Force, which still meets every month. This Task Force was instrumental in bringing the Infectious Disease Elimination Act (IDEA) aka Syringe Exchange Program (SEP) legislation to the Manatee County Board of Commissioners for approval in December of 2019, after the legislation was passed statewide on July 1, 2019 and left to each county to approve its implementation. The passing of this SEP legislation in Manatee County alone was a step toward addressing and reducing health inequities associated with access to care among people who use drugs who often go without due to their employment, transportation, and insurance statuses.

Our DOH-Manatee website can be located at: http://manatee.floridahealth.gov/index.html

The innovative practice at hand was the identification of four strategies in three domains during a CAP meeting held on February 14, 2019 with over 60 community partners, hosted by DOH-Manatee as described in previous sections. These four strategies included a prescription opioid awareness campaign, evaluation of an Opioid-focused Recovery Peer Coach Pilot program, distribution of ALTO toolkits, and provider education on alternative pain management practices, in the domains of prevention, linkage to care, and harm reduction respectively. The target population for the project included people in Manatee County who used opioids, whether prescription or illicit. In 2018 when the project began, the total county population was 400,000. Given that opioid use spans all demographic groups, including socioeconomic, as well as racial and ethnic groups, it was imperative for DOH-Manatee to use a variety of data types to understand the scope of the issue. One of the data sources used by DOH-Manatee was 2018 Narcan distribution data which included 718 data points, i.e. the total number of people who received Narcan by the Emergency Medical System (EMS) for the year. This data revealed a higher percentage of Narcan distribution among men (60%) compared to women (40%), white (87%) compared to all other racial groups (13%), and among people aged 25-34 (49%) compared to other age groups. Despite there being higher percentages of Narcan distribution among some demographic groups compared to others, what this data told DOH-Manatee staff working on the project was that opioids affected every single demographic group in the county. Narcan was distributed at least once in all ages between 0-85+ years, every racial and ethnic group, and a multitude of different locations including schools, businesses, homes, and on the street.

In addition to Narcan distribution data provided by EMS, DOH-Manatee used data from other community reports that revealed prescription opioid use in high socioeconomic zip codes that would have fallen through the cracks had they not been identified as high-use areas. This meant that the project needed to be targeted in both high socioeconomic areas in the county based on these community reports, as well as low socioeconomic areas of the county based on the EMS Narcan distribution data. Therefore, the CAP activities for all four strategies included in the three domains of prevention, harm reduction, and linkage to care, spanned all zip codes and all demographics of Manatee County through a multi-pronged approach. For example, in the prevention strategy of a prescription opioid awareness campaign, the materials used included convenience store posters and gas pump toppers that displayed the slogan "it takes a little to lose a lot" with a picture of a prescription opioid pill container. The convenience stores and gas stations that this signage was displayed in spanned across zip codes of Manatee County identified as high rates of Narcan distribution per the EMS data and with high levels of commuter, visitor, and multi-socioeconomic traffic per our knowledge of the county. Another material used in the prescription opioid awareness campaign was interior bus signage in every Manatee County Area Transit public transportation bus that travels across the busiest corridors of the county. Given that many people who use drugs lack transportation of their own and frequently rely on public transportation for travel, this route was sure to reach a multitude of demographics including our target population of people who use illicit or prescription opioids.

Based on the number of impressions across all four of the aforementioned strategies that were implemented as a result of the CAP, approximately 90% of the Manatee County population was reached. It is unclear how many of this 90% of the Manatee County population precisely included people who use illicit or prescription opioids as many of the strategies were passive, i.e. signage on public transit buses. Furthermore, another strategy was the use of 30-second television ads on a major Cable TV network that reaches millions of people on a daily basis and it would be impossible to know how many of these millions were specifically people who use illicit or prescription opioids. Due to the pervasive nature of opioid use, abuse, dependence, and addiction in Manatee County, the presumption was to reach as much of the population as possible, such that the probability of reaching people affected by opioids was high. Nothing of this magnitude had ever been attempted in Manatee County prior to the implementation of all four strategies that came out of the CAP meeting. Prior to these strategies, efforts to address opioid use included those that were undertaken by local substance abuse treatment and detox facilities, as well as medical professionals who came into contact with people who used opioids and referred them to said treatment and detox facilities. Other efforts included the Community Health Assessment (CHA) performed in 2015 by DOH-Manatee that revealed county residents' beliefs that substance use was a top concern facing Manatee County. The subsequent Community Health Improvement Plan (CHIP) that resulted from these CHA results identified substance abuse as one of nine priority areas to address over the next five years and created a subcommittee called the Addictions Task Force to do so. In addition to the Addictions Task Force, there was a Pain Management Task Force in Manatee County in operation to address alternative methods to pain management instead of opioids. While all of these efforts were promising, they were performed on a much smaller scale, compared to the Manatee County-wide efforts that resulted from the four CAP strategies.

To address health inequities, DOH-Manatee targeted all four CAP strategies by using data from various sources to understand where the highest pockets of Narcan distribution, child welfare involvement due to substance use, and prescription opioid use were across the county. Examining this data was instrumental in illuminating pockets of Manatee County where substance use and prescription opioid use in particular were unknowingly elevated and would have otherwise been overlooked. This was the primary method of addressing health inequities in the four CAP strategies because, for example, Manatee County has a large older population. This population in the county has some of the highest rates of prescription opioids due to chronic and/or age-related health conditions but this is rarely ever addressed, talked about, or focused on in the existing Task Forces addressing substance use because the focus is often on prevention of substance use in youth. What results is overlooking the older community who, due to being prescribed opioid medication by a physician, are often unaware of the risks associated with opioid use, including becoming addicted or dependent on their prescription(s). Another less spoken about issue is that of youth receiving opioids from their older family members due to the prescriptions not being disposed of or stored properly, which can lead to opioid use, abuse, dependence, and addiction in both the older and youth populations highlighting the interconnected nature of substance abuse and the need to not focus all energy toward one particular "at-risk" population over another. In terms of health inequity, it is also often overlooked that older populations may also not have equitable access to substance abuse treatment due to restricted income, transportation, or family assistance. For all of these reasons, the older population was one that was targeted in several aspects of the four CAP strategies but was not completely focused on as illicit and prescription opioid use spans all demographics, in sometimes interconnected ways.

The practice of using a CAP to develop four strategies in addressing illicit and prescription opioid use in Manatee County was both new and innovative. The second and third strategies specifically, under the theme of harm reduction, included a prescription opioid awareness campaign and provision of a statewide ALTO toolkit designed by Manatee Memorial Hospital. This prescription opioid awareness program was based on the Centers for Disease Control and Prevention (CDC) Rx Awareness Campaign that was launched in 2017, the year prior to the CAP meeting, making Manatee one of the first counties in the United States (U.S.) and the first county in Florida specifically to implement it. At the time that DOH-Manatee implemented the prescription opioid awareness campaign, the Rx Awareness Campaign slogan was "it only takes a little to lose a lot" and included print materials that showcased this slogan in addition to a prescription pill bottle. The Campaign also included several different 15- and 30-second video testimonials of real people telling their story about how prescription opioids impacted their lives or the lives of their loved ones. The notion was that, it only takes a little amount of prescription opioid pills to lose a lot like family, friends, and even ones' own life as a result. The CDC piloted the Rx Awareness Campaign in December 2016 for 14-weeks across nine high-burden U.S. cities across four different states. An evaluation of the pilot found 83%-89% of the audiences who came across the campaign materials found them effective. Furthermore, 84% of audiences found the campaign materials believable, 78% found them to be meaningful and informative, 75% found the campaign materials worth remembering, and 73% found them convincing. Since DOH-Manatee implementing the prescription opioid awareness campaign in 2019, the campaign materials have been updated with a new slogan, testimonials, and print media.

As for the ALTO toolkits designed by Manatee Memorial Hospital, the materials included in this toolkit expanded on the existing ALTO program first launched by St. Joseph's University Medical Center's Emergency Department located in New Jersey. Given the differences in population demographics between New Jersey and Manatee County, Florida, Manatee Memorial Hospital medical providers worked to adapt the toolkit so that it fit the local patient needs. Finally, the fourth strategy under the theme of linkage to care included an independent evaluation of the Opioid-focused Recovery Peer Coach Pilot program. A plethora of literature supports the use of peer recovery coaches in long-term recovery among people with addiction that the Substance Abuse and Mental Health Services Association (SAMHSA) includes the use of peer coaches in its recommended approach to the treatment of substance use disorders. The evaluation of Manatee County's Opioid-focused Recovery Peer Coach Pilot program expanded the volume of research on such programs.

Aside from the four strategies that were implemented as a result of the CAP, the CAP process itself is a common public health process in systematically identifying community challenges and how to address them. Furthermore, CAP planning is used to identify who is going to address the issue and how. The result is a framework for implementing sustainable change on the issue.  In Manatee County, this was a framework on addressing the specific issue of substance abuse and the opioid epidemic. Developing a CAP is flexible and unique to every community, as outlined by templates from the CDC, the AARP Network of Age-Friendly States and Communities, and many other agencies focused on creating community-level change.

On February 14, 2019, DOH-Manatee hosted a meeting with over 60 local, state, national and federal community partners to collaborate, develop, implement, monitor and evaluate a local Community Action Plan (CAP) to reduce fatal and non-fatal overdoses and community consequences of the opioid epidemic through prevention, harm reduction, and linkage to care. Four strategies came out of the CAP, aimed to reduce local barriers and challenges by improving coordination, combating stigma, increasing public awareness, and improving linkages to care.

Strategy 1) Prescription Opioid Awareness Campaign: DOH-Manatee planned for the campaign by reviewing materials from the CDC Rx Awareness Toolkit and participating in calls with CDC communication staff. The campaign’s tagline is “it only takes a little to lose a lot.” The materials and resources are real stories and can be used online, in print, on the radio and through the media. DOH-Manatee staff met with community partners to determine the best options for the campaign based on high-risk, at-risk, and vulnerable areas.  Strategies were specific and identified for each target group.  For example, staff received zip-code level Narcan use data to identify the highest hit corridors of Manatee County to identify where campaign materials might best be placed. Child welfare data was used to identify families that may need to be included as a target population. Because the highest hit areas were spread throughout Manatee County, different strategies were deployed.

Along with the quotes (i.e. cost) of implementing the campaign with each of these vendors, DOH-Manatee staff received  “reach” data to understand how many Manatee County residents and visitors might encounter campaign materials, including public transit bus ridership, cable TV network viewership, and newspaper subscriptions. Although staff had an idea of what type of vendors they wanted, the actual vendors selected and subsequently contracted had to meet DOH-Manatee’s budgetary requirements, use the CDC Rx Awareness campaign materials that could be easily adapted, and provide updates on progress during the campaign period. During this process, staff collaborated with the contracted vendors to select the best options for implementation based on the vendor audience. Vendors were directed to the Rx Awareness campaign website (https://www.cdc.gov/rxawareness/index.html) to obtain materials specific to their medium.

The final products of the five different Rx Awareness Campaign vendors included:

a) The Regal Oakmont 8 Movie theater implemented 30-second on-screen and lobby testimonial videos of people telling their real life stories of how prescription opioids impacted their lives or the lives of their loved ones, and digital banners of the “it only takes a little to lose a lot” slogan and picture of a prescription opioid pill bottle;

b) The Spectrum Cable TV network ran all eight of the CDC’s pre-designed Rx Awareness testimonial videos in the form of 30-second television ads on 21 different cable television networks;

c) All Star Media, a local digital media vendor, implemented 35 posters and 81 gas pump toppers depicting the “it only takes a little to lose a lot” slogan and a picture of a prescription pill bottle at 36 convenience stores and gas stations;

d) FastSigns, another local digital media vendor, implemented interior posters that depicted the slogan “it only takes a little to lose a lot” with a picture of a prescription opioid pill bottle on all 30 Manatee County Area Transit (MCAT) public transportation buses

e) The Bradenton Herald, a local newspaper, implemented two-sided newspaper inserts within week -day newspaper subscriptions, and an electronic poster advertisement (E-Blast) via email to newspaper subscribers.

Strategy 2) Evaluation of the opioid-focused peer coach program: The evaluation was performed by an independent contractor from the local University and consisted of the following components:

a) Review of existing documents, including relevant data about the opioid problem in Manatee County; program information; relevant websites, scholarly articles and other resource material;

b) Interviews with key stakeholders, including designated representatives from the Manatee County Community Services Division (Health Services), Central Florida Behavioral Health Network, DOH-Manatee, Manatee County Sheriff’s Office, Manatee County Drug Court, Manatee Memorial Hospital, Centerstone, Manatee County EMS, and First Steps to determine if the program is operating as planned and meeting stated goals;

c) In collaboration with participating partners, match program participants to official records to determine service utilization and outcomes across agencies prior to, during, and after program enrollment; and

d) As much as possible, estimate cost effectiveness of the Opioid-focused Recovery Peer Coach Pilot program. 

Strategy 3) Medical provider and medical student education classes on alternative pain management strategies:

For Healthcare Providers/Prescribers: Opioid Use Disorder in Pregnancy, Complementary & Integrative approaches to Pain Management, Multimodal approaches to Pain Management, Prescribing Opioids for Pain Management, Neurophysiology of Pain Management – Continuing Medical Education credits and Continuing Education credits provided.

For Healthcare Providers/Health Professions Students/Future Prescribers: Health Professionals’ Impact on the Opioid Crisis or Identifying, Assessing and Treating Opioid Use – only Continuing Education credits provided.

•           5/1/19 CHW & Health Care Providers conference

o          Topic: Opioid Use Disorder & Pregnancy

o          Participant total: 40 (mix of CHWs & other HC Providers)

•           5/16/19 Drug Free Charlotte County/Prescription Drug Awareness Action Committee

o          Topic: Opioid Use Disorder & Pregnancy

o          Participant Total: 15 (6 CE/1 CME)

•           5/28/19 Ramos Center Partnership

o          Topic: Pharmacology of Multi-Modal Approaches for Pain Management

o          Participant total: 4 (1 CE)

•           5/29/19 Ramos Center Partnership

o          Topic: Pharmacology of Multi-Modal Approaches for Pain Management

o          Participant Total: 8 (1 CE)

•           6/11 & 6/13/19 DeSoto Memorial Hospital

o          Topic: Health Professionals’ Impact on the Opioid Epidemic

o          Participants 18 (18 CEs)

Health Professions Student Trainings: 6 trainings, 81 participants

•           4/12/19 MTC Pharmacy Tech: 6

•           4/12/19 MTC Medical Assisting: 6

•           4/16/19 MTC Dental Assisting: 17

•           4/29/19 SCF PTA: 21

•           5/10/19 MTC LPN: 15

•           5/21/10 FGCU Nursing: 16

Strategy 4) Distribution of ALTO Toolkits: Milestones with this strategy included the development of the Toolkit with funding from a local hospital, using the ALTO program model. Furthermore, there was a merging of two different addiction task forces in Manatee County as a way to combine efforts and introduce the task force attendees to the ALTO program. This was also a way to leverage the distribution of ALTO Toolkits by asking task force attendees to share the Toolkit with their workplace. ALTO Toolkits were also distributed outside of the county, to other hospitals across the state of Florida. The toolkit was distributed to stakeholders throughout Manatee County. This also resulted in requests from hospitals statewide to which the toolkit was distributed.

The timeframe for all four strategies was between January 2019 to July 2019. As stated, over 60 community stakeholders were involved in the CAP which led to the development of the four strategies within three themes of prevention, harm reduction, and linkage to care. These stakeholders included: Ameriprise Financial, Centers for Analgesic Transformation, Centerstone, Central Florida Behavioral Health Network, Community Activist, Department of Children and Families, Drug Free Manatee, DOH-Pinellas, First Citizens Bank, First Step of Sarasota, First Step Peer to Peer, Florida Poison Information Center- Tampa, Gulfcoast Area Health Education Center, HCA Healthcare, Healthy Start Coalition of Manatee County, Lake Erie College of Medicine, Manatee County Chamber of Commerce, Manatee County Government, Manatee County Pastors, Manatee County Sheriff's Department, Manatee Memorial Hospital, Operation PAR, Physical Therapy Doctors of Central Florida, Ramos Center for Interventional and Functional Pain Medicine, Synergy Medical, Turning Points, University of South Florida, U.S. House of Representatives, and, Westminster Communities of Florida.

DOH-Manatee was responsible for planning the CAP meeting, inviting the 60+ community partners to the meeting, scheduling and coordinating the presentations given at the meeting, facilitating the CAP activities, and conducting the SWOT analysis. After the CAP, DOH-Manatee was responsible for completing reports and updates for all four strategies, the procurement of the independent evaluator for the Opioid-focused Peer Recovery Coach Program pilot, oversight of the evaluation process, procurement for the vendors that implemented the opioid awareness campaign, and ongoing work with these vendors to manage and shift the campaign as needed. DOH-Manatee also participated in technical assistance calls and meetings with the CDC and NACCHO regarding the opioid awareness campaign and the evaluation process of all four strategies. Administratively, DOH-Manatee processed invoices related to project costs and managed the budget for all four strategies. And finally, when reports were ready to be disseminated, DOH-Manatee was responsible for reporting the results at various community meetings.

The total project budget was $65,000 and included the following activities:

- Prescription Opioid (Rx) Awareness Campaign:  $30,000 (includes vendor costs, and partial staff costs);

-Evaluation of the Opioid-focused Recovery Peer Coach Pilot program: $35,000 (includes contracted evaluator and partial staff costs); and,

-Provider Education: $0.00 as this project, a community provider (Gulfcoast AHEC) received a separate grant to implement.  

The objectives of the project were to develop and implement a Community Action Plan (CAP) to reduce fatal and non-fatal overdoses and community consequences of the opioid epidemic through prevention, harm reduction, and linkage to care; and monitor and evaluate CAP efforts. What was learned during the project included the identification of high-risk, at risk, and vulnerable areas throughout Manatee County through a multitude of different data sources. A corresponding multitude of different campaign strategies were employed by DOH-Manatee to leverage the greatest reach within these areas of greatest need. For example, DOH-Manatee designed and implemented the campaign on public transit, in movie theaters, and in convenience stories/gas stations throughout zip codes with the highest number of Narcan doses administered in 2018. Furthermore, DOH-Manatee intentionally included areas throughout Manatee County that may not have otherwise been on the radar for opioid use and overdose based on results obtained from the Handle with Care and Lakewood Ranch Brain Health initiatives. The extent that the objectives were achieved included a preventative prescription opioid awareness campaign, the practice of harm reduction techniques including provision of alternative pain medication education and ALTO toolkits to medical providers, and the evaluation of linkage to care through an Opioid-focused Recovery Peer Coach Pilot program.

A mixed-method evaluation of the Opioid-focused Recovery Peer Coach Pilot program was conducted by an independent evaluator who was procured by DOH-Manatee from a local University. The results of this evaluation included both quantitative empirical data analysis as well as qualitative focus groups with administrators and peer coaches from the Program. The Opioid-focused Recovery Peer Coach Pilot program emerged from the 2015-2020 Community Health Improvement Plan (CHIP) completed by DOH-Manatee, in which one of nine strategic issues was to decrease the rate of substance use, overdoses, and co-occurring behavioral disorders in Manatee County. One recommendation that came forward as a way to address this strategic issue was the establishment of a peer support program that would help increase the availability of preventative and treatment services through linkage to care. The Manatee Board of County Commissioners submitted a $500,000 legislative budget request for its Health Care Services Office to design and implement what would become the Opioid-Focused Recovery Peer Coach Pilot program. The program started in July 2018 after a local treatment agency applied for and became the host agency to implement the program, and it was in operation for one year prior to the evaluation.

The evaluation aimed to answer the following questions: 1) is the Opioid-focused Recovery Peer Coach Pilot program operating as designed? If not, what challenges/barriers are they facing and how might those be addressed?;  2) how many people are receiving services through the Program, who are they, and how are they being served? If they are not being adequately served, what are the barriers to treatment and other services?; 3) to what extent has the Program affected linkage to care? What resources are participants being referred to? Are they following up with referrals? If not, what are the barriers?; 4) are individuals served by the program demonstrating positive outcomes? Measures included decreased: overdose incidence, EMS calls, emergency room visits, hospitalizations, inpatient detox stays and/or decreased time in between stays, residential substance abuse treatment stays, medication assisted treatment services, Narcan administrations, and arrests. Measures also included increased: outpatient detox services, medication assisted treatment services if helping in recovery, stabilized living conditions, gainful employment, and family reunification, if applicable.; 5) is the Program demonstrating cost-savings?; 6) to what extent is the effectiveness of the Program communicated?; and, 7) what resources and supports are needed to sustain the program?

As mentioned the evaluation was mixed-method including quantitative and qualitative components. For the quantitative component, primary data sources included EMS Narcan distribution; Opioid-focused Recovery Peer Coach Pilot program participant case files; local treatment facility data to link with Program participants to determine service utilization prior, during, and after Program enrollment; and, law enforcement data to determine arrests as well as jail stays. Qualitative primary data sources included interviews with key stakeholders including Program participants, Program peer coaches, and representatives from the Manatee County Health and Human Services Department, Central Florida Behavioral Health Network, DOH-Manatee, Manatee County Sheriff's Office, Drug Court, Manatee Memorial Hospital, Centerstone, EMS, and First Step substance abuse treatment facility. Secondary data sources included the review of relevant websites, existing literature both peer-reviewed and media, and other documents related to the opioid epidemic in general as well as in Manatee County specifically, and peer coach programs.

In order of evaluation questions, the first question (whether the Opioid-focused Recovery Peer Coach Pilot program was operating as designed, and if not, what challenges/barriers are faced and how might those be addressed) was analyzed through comparison of the scope of work for the Program versus the reality of its operation. The independent evaluator first sifted through the program operational guidelines for the Opioid-focused Recovery Peer Coach Pilot program and listed the requirements based on these guidelines for how the Program was to be implemented. Job expectations for the peer coaches employed by the program were included in this analysis. The independent evaluator then interviewed peer coaches as well as representatives at the treatment agency that hosted the Opioid-focused Recovery Peer Coach Pilot program to compare what was happening in real time, to the guidelines and job descriptions. Results revealed that the peer coaches employed by the Program were satisfying job duties as described in the official job descriptions, despite challenges with state background checks during the onboarding of new peer coaches due to the inherent nature of their being in recovery and perhaps having prior criminal records due to their past drug use. As for the program operational guidelines, results showed the Program to be in compliance with the core values outlined by SAMSHA and also with the recommendations for successful practice. The records kept by peer coaches were shown to be HIPAA compliant, with records being kept properly albeit challenged by missing participant information. This missing participant information normally occurred after participants were back in the community and not complying with the 90% face-to-face services outlined in the program guidelines, lost contact with the program, or did not have reliable communication methods like a telephone. Suggestions to address these barriers included changing program requirements from 90% face-to-face services to more text- and - telephone based for those who have access to these communication methods and taking more time with participants in the beginning before assessments are required in order to gain greater trust and program retention.

The second evaluation question (how many people are receiving services through the Program, who they are, and how they are being served) was addressed through reviewing participant case files as well as data from the host treatment agency. The independent evaluator gathered the total number of people who engaged with the Opioid-focused Recovery Peer Coach Pilot program between the inception in July 2018 through June 2019 when the evaluation took place. There were 33 participants in open group meetings that did not occur frequently; 1,479 participants in closed group meetings that took place in jail or drug court every week; 409 participants who had a new engagement in the Program; 32 peer coach recovery plans completed; and, 16 active participants at the time of the evaluation. The Program director provided the independent evaluator the demographics of 115 participants who completed an initial assessment demographic form, which included about half-and-half male/female, a range in ages from 18-64 years with the majority of participants being in their 30s or 40s, and no race/ethnicity data was collected. The average amount of time that participants spent in the program was 3.8 months, and based on peer coaches' reporting, the majority of participants experienced some sort of trauma including physical and/or sexual abuse. While the program was focused on opioids, participants also commonly used alcohol, amphetamines, marijuana, and cocaine. Participants were also commonly low-income, uninsured, and had unstable living situations. The services provided to Program participants included open and closed group sessions that were informational and therapeutic in nature, individual recovery plans, and peer coaches often attended appointments with participants as a form of support. Participant barriers to accessing the services provided included participants' lack of trust in the peer coach and/or motivation to participate in the program, and the instability of their living situations including lack of transportation, communication devices, employment, and lack of family/friend support.

 The third evaluation question (what extent the Program affected linkage to care, which resources were participants being referred to, and whether they were following up with referrals) was analyzed by the independent evaluator through Program records and conversations with peer coaches. Results revealed the Program to positively impact the linkage to care of participants to community services among those participants who are actively engaged in the Program. Specifically, participants were shown to have better coordination of care between the Program, jail, hospital, and drug court, and participants are being linked to a wider range of community resources as well including housing, food, and health and mental health care services. While these are positive results, barriers noted by peer coaches were many participants did not follow through with referrals due to their lack of transportation, communication methods, and having unstable living conditions.

The fourth evaluation question (whether participants served by the program were demonstrating positive outcomes) was answered by the independent evaluator through data provided by the Opioid-focused Recovery Peer Coach Pilot program, admissions data provided by the local hospital and Central Florida Behavioral Health Network, jail time and mental health services data also provided by Central Florida Behavioral Health Network, and EMS data. Program participant data was linked to these other data sources to build a better picture of their trajectory before, during, and after Program participation. Many of the outcome measures included in the prior description of evaluation questions could not be answered due to data unavailability. The available results revealed 12 of 54 (22%) Program participants included in the analysis received EMS services between the year prior to Program inception, July 1, 2017 through July 1, 2019. Additionally, 31 out of 54 (57.4%) had an emergency room visit due to substance abuse prior to their enrollment in the Program, with only 10 participants having emergency room visits due to substance abuse after enrollment in the Program. There was also a decrease in outpatient services, medical services, substance abuse interventions, crisis services, crisis stabilization unit stays, and mental health residential stays by Program participants pre- versus post- Program enrollment.

The fifth evaluation question was whether the Opioid-focused Recovery Peer Coach Pilot program was cost effective. The independent evaluator analyzed cost data on jail days, mental health services, Narcan administration, emergency room visits, and EMS calls to illuminate what these services cost, if used. Not all of this data was found, but what the independent evaluator gathered included: jail stays amount to $129 per day in Manatee County; the cost of a single Narcan administration kit ranges from $22-$60; and, the average ER visit at the local hospital costs $5,950. The independent evaluator concluded that the Opioid-focused Recovery Peer Coach Pilot program decreased participants' use of many emergency services as previously outlined, saving the cost of these services to Manatee County.

The sixth evaluation question addressed to what extent was the effectiveness of the Opioid-focused Recovery Peer Coach Pilot program communicated. The independent evaluator found that prior to their evaluation, no data on the effectiveness of the Program was available in Manatee County. Finally, the seventh evaluation question addressed sustainability and whether the Program could be sustainable over time. The conclusion made by the independent evaluator was that the Program was not sustainable in the way that it was operating at the time, being funded as a pilot, carried out as an individual program, and had no means of generating an income. Modifications were not made to the practice as a result of this evaluation because shortly after the evaluation, the legislative funding for the Program was cut.

Sustainability for the project has continued to this day and will proceed to be sustained into the future because it was derived from the 2015-2020 CHIP conducted by DOH-Manatee. To provide the necessary history, every five years (now three years due to accreditation requirement changes) every county Florida Department of Health is required to perform a community health assessment (CHA) and based on the results from the CHA, a community health improvement plan (CHIP) to address the top concerns as indicated by county residents who responded to the CHA. Both the CHA and the CHIP are directly influenced not only by the county residents who participate in the CHA survey, but by a multitude of key stakeholders in the Manatee County community. These stakeholders are involved in the CHA and CHIP processes primarily through their participation in the Manatee County Health Care Alliance, Inc. (MHCA), which was established in 2010 and facilitated by DOH-Manatee to encourage community engagement among residents and professionals interested in health care. During the 2015-2020 CHA and CHIP processes, the MHCA helped to identify the top issues facing Manatee County as indicated by county residents in the CHA. Nine different priority areas were designated to be addressed by the CHIP, forming one subcommittee for each of these nine issues, with nine subcommittees in total.

Substance abuse was one of the top issues indicated by Manatee County residents who participated in the CHA survey and was subsequently chosen as one of the nine strategic issues to be addressed through the CHIP by MHCA stakeholders. A subcommittee was formed called the Addictions Taskforce and this subcommittee continues to meet monthly to this day. In addition to this Addictions Taskforce, DOH-Manatee hosted a meeting on February 14, 2019 with over 60 local, state, national and federal community partners to collaborate, develop, implement, monitor and evaluate a local Community Action Plan (CAP) to reduce fatal and non-fatal overdoses and community consequences of the opioid epidemic through prevention, harm reduction, and linkage to care. During this CAP, the community partners broke out into groups to perform a Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis of Manatee County to determine a strategic plan for accomplishing the CAP goals of reducing fatal and non-fatal overdoses as well as the community consequences of opioids. The three strategic areas that came out of the SWOT analysis included prevention, harm reduction, linkage to care, with four specific strategies to combat these three areas including provider education, ALTO kit distribution, a prescription opioid awareness campaign, and an evaluation of an Opioid-focused Recovery Peer Coach Pilot program. All of these strategies have been described elsewhere in this application and are covered here to provide clarity on how the CHA and CHIP, MHCA, and CAP piece together in terms of sustainability to be discussed hereafter.

The primary lesson learned in relation to practice is the sheer power of partnerships when it comes to addressing the opioid epidemic. It took every single partner's expertise, input, and effort to accomplish the goals surrounding the four strategies that emerged from the CAP. This is because the real work began after the CAP planning meeting, when implementing the four strategies happened. Lessons learned from the prescription opioid awareness campaign included using data from a multitude of sources including child welfare, brain health, and EMS, to illuminate pockets of Manatee County experiencing high rates of prescription opioid abuse that were not previously on the radar. As for the evaluation of the Opioid-focused Recovery Peer Coach Pilot program, lessons learned included the importance of an interconnected system of health data collection among high-service users, to better understand the health care needs of people who use opioids and/or who are in recovery. Lessons learned in the provision of ALTO toolkits and provider education on alternative pain management practices were that there is such a dearth of information and alternative practices available, but if providers are not receiving this information, they may not be aware it exists. Social stigma in the healthcare industry toward people who use opioids still exists and without the infiltration of proper education on addiction or knowledge about more appropriate prescribing methods, as well as alternatives for opioids altogether, some health care professionals simply remain unaware of how to more appropriately treat this patient population.

Lessons learned in terms of partner collaboration has continued to this day. Through the MHCA, ongoing participation in the nine CHIP subcommittees, and the updating of the 2020 CHA and CHIP processes recently, DOH-Manatee maintains relationships with all of the community partners who participated in the CAP in February 2019. The biggest lesson learned is continuous engagement is imperative to keep substance use, specifically opioid use, on the forefront of community partners' minds as different issues naturally arise over time. For example, while opioid use continues to be an issue in Manatee County today, the rise of methamphetamine use has also become a concern in recent months such that the focus of the Addictions Task Force has broadened to include this drug class as well. This has worked out seamlessly only because the Task Force still meets monthly, communicates regularly, and has large enough participation that while some of the group members continue to focus on opioid use prevention, other members can simultaneously focus on the rise in methamphetamine use as well. Without the continued engagement of this Task Force, it would have been difficult to introduce an entirely new drug class to incorporate and strategically address through the goals and objectives of the group.

A cost/benefit analysis was attempted during the evaluation of the Opioid-focused Recovery Peer Coach program as previously described. As mentioned in this section, one of the lessons learned from this Pilot program evaluation was that there needs to be a better, interconnected system of data related to health care service utilization among people who use drugs and/or who are in recovery. The cost/benefit analysis was not incredibly informative because of the lack of data on service utilization among the Pilot Program participants, the lack of updated data on Narcan distribution, and the cost of mental health and substance abuse treatment programs. An interconnected, electronic health system shared among medical, mental health and substance abuse, and emergency health providers may assist with better cost/benefit determinations.

Manatee County is a unique community, in that community leaders not only want to know more about substance use and how to effectively address it, they care enough to commit to action. There has been a large MHCA attendance since its inception in 2010, there is a large stakeholder attendance at every Addictions Task Force subcommittee meeting, and these community stakeholders were the same individuals who attended the February 2019 CAP meeting that created the four strategies being submitted here for the Model Practice Award. Many of the specific four strategies were time limited and may not be specifically happening today, i.e. the evaluation of the Opioid-focused Recovery Peer Coach Pilot program was a one-time evaluation of a one year pilot peer coach program.  However, all four strategies laid the foundation for practices that are happening today. For example, the prescription opioid awareness campaign laid the foundation for another awareness campaign that took place between September-December 2020 focusing on how to safely practice harm reduction during the COVID-19 pandemic. Similar techniques were used in this most recent campaign as the prescription opioid awareness campaign, including gas pump toppers, convenience store posters, interior signage on all of the Manatee County public transit buses, and newspaper inserts distributed through the Bradenton Herald. It was because of the partnerships formed with the vendors from the prescription opioid awareness campaign that made the most recent harm reduction during COVID-19 campaign so successful.

Another exciting development that came from the harm reduction strategy created during the CAP meeting was the County Board of Commissioners' approval of a county Syringe Exchange Program (SEP) in December 2019, following the statewide legislation approving SEPs in July 2019. Prior to introducing the term 'harm reduction' in terms of the peer coach pilot program, this term was not commonplace in Manatee County and it was only through the committed efforts of community stakeholders through the CAP and its strategies that harm reduction techniques became more understood and accepted in the county. The SEP will provide sustainable harm reduction services to people who use drugs in Manatee County on top of the harm reduction efforts already underway in another, related, grant obtained by DOH-Manatee in January 2020 that is a three-year cooperative agreement between the Centers for Disease Control and Prevention (CDC) and the National Association for County and City Health officials (NACCHO) in partnership with local health departments. This grant is called opioid-related Overdose Data to Action (OD2A) and was applied for by DOH-Manatee as a direct result of how successful the CAP strategies of the prescription opioid awareness campaign and evaluation of the Opioid-focused Recovery Peer Coach Pilot program were. Grant activities include the provision of harm reduction classes, a harm reduction during COVID-19 awareness campaign as previously described, and provision of youth and adult mental health first aid classes to community members. Another activity includes a targeted digital 'landing page' created by DOH-Manatee in collaboration with a local vendor, which is a webpage that individuals may be directed to after clicking on a targeted substance-abuse related ad if they are algorithmically-identified by posting substance use related content on social media or performing substance use related Google searches. This landing page individuals are directed to displays mental health and substance abuse hyperlinks, information, and resources for over ten different Manatee County community mental health and substance abuse treatment providers, law enforcement, and emergency resource agencies. All of these three-year cooperative grant activities will extend through September 2022, with the exception of the digital landing page that will remain live with no expiration date. This means for harm reduction education and youth and adult mental health first aid training, DOH-Manatee will have at least two more years’ worth of sustainability efforts toward reducing substance abuse, opioid overdose, and the community repercussions of the opioid epidemic.

Aside from the ongoing harm reduction efforts in Manatee County, the subcommittees and community engagement are part of the sustainability plan as well. Two of the main substance abuse Task Forces in Manatee County - the Addictions Task Force and the Pain Management Task Force - joined together to form one larger Task Force in 2019. The new, larger, group is called the Pain Management and Addictions Task Force and meets once per month to this day. The most recent meeting addressed how to ensure the sustainability and effectiveness of the Task Force through applying to grant announcements received by DOH-Manatee regarding the ongoing opioid epidemic. Oftentimes these grant announcements may be sent to DOH-Manatee but must be applied for by specific types of community agencies while facilitated by a local department of health. DOH-Manatee, therefore, continues to attend these Task Force meetings as a facilitator of information, engagement, and grant resources for community partners to sustain their efforts toward the reduction of substance use and specifically opioid overdose.